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Blindness in nepal

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BLINDNESS IN
NEPAL
PRESENTER :MANISHA DAHAL
4TH YEAR
B. OPTOMETRY, IOM

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Presentation Layout
Introduction to blindness
Epidemiology
Midterm Review of Vision 2020
Causes of blindness
 Disease...

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Definition Of Blindness
 WHO has classified visual impairment and
blindness into various grade:
(Best available correctio...

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Blindness
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Blindness in nepal

  1. 1. BLINDNESS IN NEPAL PRESENTER :MANISHA DAHAL 4TH YEAR B. OPTOMETRY, IOM
  2. 2. Presentation Layout Introduction to blindness Epidemiology Midterm Review of Vision 2020 Causes of blindness  Diseases burden Blindness control
  3. 3. Definition Of Blindness  WHO has classified visual impairment and blindness into various grade: (Best available correction in the better eye) 6/6-6/18 Normal vision <6/18-6/60 visual impairment <6/60-3/60 Severe visual limpairment <3/60-NPL BLIND <1/60-PL BLIND NPL BLIND
  4. 4. Defining Blindness  Economic Blindness: ― The level of blindness that prevents an individual from earning his wages. ― Vision less than 6/60 with the better eye with best correction.  Legal Blindness: ― The level of blindness that necessitates welfare measures and legal protection ― Vision less than 6/60 in better eye with best correction and visual field less than 10 degree.
  5. 5. Defining Blindness  Social Blindness ― Hampers an individual from socially interacting with the family and peer groups in a satisfactory manner ― Vision less then 3/60 with the better eye with best correction.  Manifest Blindness ― Constraints the accomplishment of tasks for daily living leading to impairment in mobility and corresponding to a vision of 1/60.
  6. 6. Defining Blindness..  Absolute Blindness ― Inability to perceive light secondary to irreversible damage to the nerve carrying the visual signals Eg: Optic atrophy  Curable Blindness ― The stage of blindness where the damage is reversible by prompt management. Eg: Cataract
  7. 7. Defining Blindness..  Preventable Blindness ― The loss of vision that could have been completely prevented by institution of effective preventive and prophylactic measures. Eg: Xerophthalmia and trachoma  Avoidable Blindness ― The sum total of preventable and curable blindness ― 90% of blindness in our country is avoidable. ― EG: Cataract ,Refractive error
  8. 8. Defining Blindness..  Incurable Blindness ―The stage of blindnes that cannot be treated, prevented and cured is called incurable blindness. ―5-10% of all blindness fall in this category.
  9. 9. Blinding Eye Diseases  Cataract  Glaucoma  DiabeticRetinopathy ― Occurs everywhere ― Affects individuals ― Affects mainly adults ― Requires surgery/ laser ― Needs an eye doctor  Trachoma  Onchocerciasis  Vit A deficiency ― Focal disease ― Affects Communities ― Starts in chilldren ― Requires medicine ― No need eye doctor Hospital based Community based
  10. 10. 253 million people are visually impaired globally 217million have low vision 36 million are blind Fact Sheet N°282 WHO- August 2017
  11. 11. EPIDEMIOLOGY  About 90% of the world's visually impaired live in low- income settings.  81% of people who are blind or have moderate or severe vision impairment are aged 50 years and above .  Un-operated cataract remains the leading cause of blindness in low- and middle-income countries.  80% of all visual impairment can be prevented or cured. Fact Sheet N°282 WHO- August 2017
  12. 12.  Cataract (51%) is the most common cause of blindness in the world (Pascolini et al, 2011).  Moreover, trachoma and childhood blindness are responsible for 15% and 4% of all blindness respectively. Country No.of blinds No. of low vision No. of Visual Impairment CHINA 8.2 million 67 75 INDIA 8 million 54 62 AFRICA 5.8 million 20 26
  13. 13. Blindness prevalence in Nepal  Nepal Blindness Survey conducted in 1981 revealed that of the Nepalese populations are blind and 1.7 % has unilateral blindness.  Compared with the NBS the prevalence of blindness (all ages) reduced from 0.84% in 1981 to an estimated 0.35% in 2011, a reduction of 58%.  90% of the blinds reside in rural areas 0.84
  14. 14. Blindness prevalence in Nepal cont…  Nearly 80% of blindness in nepal is avoidable,either preventable or treatable  Cataract is the major cause of blindness(66.80%)
  15. 15. Blindness prevalence in Nepal cont..  330,000 of children have refractive errors  2/3 of male and female has got no eye services  90% of children have got no eye services  Total num of peolple suffering eye disorders= 70-80 lakhs,  But only 25-26 lakhs are getting eye services.
  16. 16. Blindness prevalence in Nepal cont..  Every day 125 Nepalese become blind ( 7 children)  Every day 2 children die due to Vitamin A deficiency  In Nepal we have 210000 blind people,every year increases by 24000  Blind children- 30200,every day 7 become blind.
  17. 17. Milestones on Eye Care Services 1980: Establishment of HMG/WHO, Prevention and Control of Blindness project 1981 : National Blindness Survey
  18. 18. Presenting Visual Acuity Categories WHO Categories Nepal 6/6-6/18 NORMAL VISION NORMAL VISION <6/18-60 MOD VISUAL IMPAIRMENT MOD VISUAL IMPAIRMENT <6/60-3/60 SEVERE VISUAL IMPAIRMENT Blindness (Economic Blindness) <3/60-NPL BLIND Blindness (Social Blindness) <1/60-NPL BLIND Blindness (Manifest Blindness) NPL BLIND Blindness (Absolute Blindness) Categories of visual impairment used in Nepal surveys and by WHO definition Distance visual acuity with available correction
  19. 19. People with PVA<3/60 in better eye Treatable Preventable Permanent Zone PHC/ PEC Ophth. services Bagmati 53% 7% 7% 33% Bheri 68% 14% 8% 11% Dhawalagiri 57% 5% 12% 26% Janakpur 72% 10% 8% 10% Karnali 75% 8% 10% 8% Kosi 66% 7% 4% 22% Lumbini * Mahakali+Seti 67% 8% 13% 13% Mechi 79% 6% 5% 10% Narayani * Rapti 56% 19% 0% 25% Sagarmatha 72% 5% 5% 18% Nepal(Weighted) 66% 9% 7% 19% Categories of avoidable bilateral blindness in the sample population in 14 zones.
  20. 20. Males Females Total Zone % % % Bagmati 0.9% 0.7% 0.8% Bheri 2.7% 4.0% 3.4% Dhawalagiri 0.9% 0.9% 0.9% Gandaki 0.9% 1.2% 1.1% Janakpur 1.8% 2.2% 2.0% Karnali 1.1% 2.3% 1.6% Kosi 1.6% 2.8% 2.3% Lumbini 1.8% 1.6% 1.7% Mahakali + Seti 2.4% 2.9% 2.7% Mechi 1.9% 2.5% 2.2% Narayani 5.6% 7.1% 6.4% Rapti 1.0% 1.2% 1.1% Sagarmatha 0.8% 1.6% 1.2% Nepal (weighted) 1.9% 2.3% 2.1% Prevalence of bilateral blindness in sample (pinhole VA<3/60 in the better eye)
  21. 21.  High prevalence of blindness in Narayani Zone (actually only Rautahat District) due to  High incidence of cataract in the Terai area,  High level of illiteracy in the population surveyed (93.1%),  Low cataract surgical coverage (37.3%),  Unsatisfactory visual outcome of cataract operations.
  22. 22. Nepal Blindness Survey (NBS 1981)  0.84 % Bilaterally blind  1.7 % Blind in one eye  1.85 % Low vision  80 % of the blindness are AVOIDABLE
  23. 23. What is avoidable blindness? Blindness that can be treated or prevented  Cataract  Glaucoma  Diabetic retinopathy  Corneal infections  Ocular trauma  Refractive error
  24. 24. Situation Analysis  Overall Blindness Prevalence 0.84  Male 0.68%  Female 0.99 % Male 41% Female 59% Gender distributionof blindness
  25. 25. Cause of Blindness, 1981 Catataract 72% Retinal Diseases 3% Glaucoma 3% Trachoma 3% Other infection 3% Trauma 2% Small Pox 2% Amblyopia 1% Nutritional 1% Miscellaneous combination 8% Undertermined 2%
  26. 26. Global Causes of blindness  Unknown 21%  ARMD 5%  Glaucoma 8%  Diabetic retinopathy 1%  Childhood blindness 4%  Trachoma 3%  Corneal opacities 4%  Refractive errors 3% Cataract 51%
  27. 27. Milestones…. 19 November 1999:  Vision 2020 launched in Nepal during ophthalmic Conference of SAARC countries August -September 2001 :  “National Plan of Action” prepared after two intensive workshops Analysis of four key strategies 1.Reduction of diseases burden 2.Development of infrastructure and technologies Equip all the eye hospitals and eye departments with modern cataract surgery sets, Develop retina subspecialty in peripheral eye hospitals
  28. 28. 3.Human resource development and strengthening  Initiate bachelor optometry program ,MD ophthalmology 4. Advocacy and policy formulation and execution  Strengthening co-ordination,  Establish primary eye care centers, Promote eye health education-public
  29. 29. Baseline information 2000 when vision 2020 launch  Bheri – Lumbini Survey 1997  Prevalence of Blindness VA<6/60  1981 – 1.32%  1997 – 0.85 %  Cataract Blind Prevalence 4.1% same as 1981
  30. 30. Blindness Surveys 2008-2010 Method:  WHO recommended protocol for Population based survey and Rapid Assessment for Avoidable Blindness (RAAB) applied  Survey was carried out in 12 sampling frame of the country  A total of 39,908 patient aged 50 years and over were examined in 596 randomly/ Systematically selected cluster
  31. 31. Method contd.  Door to door household enumeration was carried out in selected cluster.  Presenting and best corrected (PH) visual acuity was assessed by an Ophthalmic Assistant.  Anterior segment, media and ocular fundus evaluation was carried out by an Ophthalmologist in centrally located places in each cluster
  32. 32. Sampling frame and clusters S. No Zone Clusters Total examined 1 Mahakali and Seti Zone 52 2513 2 Bheri 61 2993 3 Karnali 24 1171 4 Rapti 59 2921 5 Lumbini 30 5138 6 Dhaulagiri 61 2990 7 Gandaki 25 5002 8 Bagmati and Janakpur 74 3613 9 Sagarmatha 59 2914 10 Koshi 59 2895 11 Mechi 62 3041 12 Narayani 30 4717 Total 596 39908
  33. 33. Prevalence of Blindness Prevalence of Blindness Comparison to the data of 1981 Zone <3/60, 1981 <3/60, 2010 <6/60, 2010 Mechi 0.64 0.38 0.79 Koshi 0.99 0.35 0.84 Sagarmatha 0.98 0.21 0.6 Janakapur 0.73 0.22 0.52 Bagmati 0.62 0.22 0.52 Narayani 0.99 0.98 2.8 Gandaki 0.46 0.23 0.42 Dhaulagiri 0.53 0.22 0.5 Lumbini 0.75 0.37 0.53 Rapti 0.87 0.3 0.52 Bheri 1.26 0.57 1.12 Karnali 1.63 0.5 0.83 Seti 1.24 0.44 0.76 Mahakali 0.8 0.44 0.76 All 0.84 0.39 0.82
  34. 34. Distribution of Blindness PVA <6/60 0.4% to 0.6% 0.6% to 0.8% 0.8% to 1.0% >1%
  35. 35. Prevalence-gender specific Male, 0.74, 43% Female, 0.99, 57% PVA <6/60 Male, 0.32, 41% Female, 0.47, 59% PVA<3/60
  36. 36. Cause of Blindness 2012
  37. 37. Cause of Blindness comparison 1981 and 2012 Cataract 65% Retinal Diseases 9% Cornea 6% Glaucoma 5% Refractive Error 4% ARMD 4% 2012 Globe abnormality 3% Other/u ndeterm ined 2% Trachoma 1% Diabetic Retinopathy 0.2% Catataract 72% Retinal Diseases 3% Glaucoma 3% Trachoma 3% Other infection 3% Trauma 2% Small Pox 2% Nutritional 1% 1981 Undertermined 2% Surgical Complications 1%
  38. 38. Estimated present Burden of Blindness in numbers Assumed prevalence 0.82% (VA<6/60)  Population base 30,000,000  Total blind 246,000
  39. 39. Burden of Blindness - CATARACT  Leading cause of blindness in Nepal, accounting for more than two-thirds of blindness  More than 80% of all avoidable blindness in nearly every geographical and demographic group.  Approximately 20% of cataract cases are blind.
  40. 40.  Mechi Zone (77.5%) has the highest proportion of cataract and Rapti Zone the lowest (40.7%). NBS 1981  5% of all blindness due to bilateral cataract occurs in persons younger than 50  Population 50+ in 2011 was 30% more than in 2001  In term of numbers of patients with bilateral cataract blindness, the number actually increased in Narayani and only reduced slightly in Janakpur, Mechi and Lumbini. NNJS 2011 CATARACT cont…
  41. 41. Achievement  In 1981, one third of all aphakic Nepali’s had been operated in India,  In 2009 all operations were conducted in Nepal.  On top of that about 71% of the 198,000 cataract operations in Nepal were conducted on Indian patients. CATARACT cont…
  42. 42. Risk factor for cataract  Increased age :(More than one-third of those over the age of 65 have cataract)  female sex: (Females are 1.35 times more likely to have cataract than males.)  Increased exposure to sunlight : People lexposed to more than 11 hours of daily sunlight were nearly three times as likely to have cataract, compared with people living where there was less than 8 hours of sunshine.
  43. 43. Burden of blindness -Corneal blindness  Second leading cause of blindness Variety of causes :  Xerophthalmia,  Trachoma,  Injuries (accidental, iatrogenic)
  44. 44. Burden of blindness -TRACHOMA  Is a chronic and contagious infection that eventually causes blindness.  Tends to occur in clusters, often infecting entire families and communities.  Infection by trachoma do not instantly go blind- the disease manifests gradually.
  45. 45. Trachoma cont..  Second leading cause of preventable blindness .  Of the 39 887 people examined, 2770 had trachoma with or without blindness.  Causes 1% of the blindness in Nepal.  LOCATION: Most trachoma is located in the Far Western terai .
  46. 46. Highest prevalence rates occur ;  Among females more than males  Among the Tharus, most of the Far Western terai, after magar and chetris (85% trachoma blindness)  Among children under the age of 10 years  Among older women.  Among women over the age of 30 years. (((Repeated re-infection among women is related to their constant contact with infected children.)))
  47. 47. Trachoma hyperendemic areas of Nepal.
  48. 48. Status of trachoma in nepal  NNJS and MoHP, initiated the "National Trachoma Program" in 2002 with the goal to eliminate trachoma from Nepal and has successfully reduced trachoma prevalence in endemic areas.  20 districts were found as trachoma endemic districts having prevalence of active trachoma more than 10%;  WHO recommended SAFE strategy was implemented in trachoma endemic districts;  SAFE stands for; “ S” for Surgery, “A” Antibiotics, “F” for face washing , “E” for environment improvement;
  49. 49.  In ten years of SAFE implementation in the trachoma endemic districts of Nepal, the program has achieved a great success in combating trachoma.  Active trachoma prevalence now has been reduced more than 90 percent in 12 program districts where SAFE was implemented,  And blinding trachoma has been prevented in 18,000 people through Trichiasis surgery.  The ultimate goal of the NTP is the elimination of blinding trachoma from Nepal by 2017.
  50. 50. Burden of Blindness - Xerophthalmia  NBS (1980)  1.65(Bitot'spot) 0-72months  Mechi (1998)  0.67(Bitots) 5-15 yrs  Kathmandu (2003)  0.36(Bitots) 5-15 years  Persistence of problem  Need for surveillance system
  51. 51. Nutritional blindness (xerophthalmia ) Location: Eastern and Central terai (more than 2/3 of Bitot's spots ) prevalence of xerophthalmia  Males : 1.5 times more than females for all age groups.  23.5% of persons under the age of 6 years.  Highest prevalence of Bitot's spots in boys aged 5-14 years.  Boys account for about (59.3%o) of the cases of Bitot's spots and active xerophthalmia (62.9%).
  52. 52.  In children under 6 years prevalence rate XIA = 0.22 per 100 children XIB =0.64 per 100 children  Bitot's spot : Three times as common as conjunctival xerosis in children.  xerophthalmia-related corneal scars : 0.2%, From the survey data, the Eastern and Central terai
  53. 53.  Risk factors  Living in crowded and unsanitary conditions,  Reduced consumption of certain vegetables, intermittent periods of food shortages  Children of poor families with a low social and economic status.
  54. 54. Burden of Blindness - Childhood Blindness  1.12/1000 children are blind  13,200 children are blind  Seven children become blind every day in Nepal
  55. 55. Major cause of childhood blindness in Nepal  Vitamin A deficiency  Trachoma  Trauma  ROP  Congenital cataract  Congenital glaucoma  Amblyopia  Refractive errors
  56. 56.  Corneal diseases = (22.8%)  Retinal dystrophy =(18.4%),  untreated cataract in 5.9%,  whole globe abnormalities= 16.7%students  Glaucoma = 8.1%  Optic nerve = in 8.7%  uveal disorders= 5.0%  RE =2.4% Causes of Blindness and Visual Impairment among students in Integrated Schools for the Blind in Nepal Jyoti Baba Shrestha1, Subodh Gnyawali2, and Madan Prasad Upadhyay2 2014
  57. 57. Burden of Blindness -Prevalence of Refractive Errors  153 million people with visual impairment due to uncorrected refractive errors  Mechi study 2.9%, Kathmandu 8.1%  Recent Survey in higher socio economic circle student shows 21% (Kathmandu valley)  Assumed prevalence : 5%  About 8.5 million school age  Number of children with significant refractive errors : 425,000 NNJS refractive error and low vision 2006
  58. 58. Burden of Blindness: Glaucoma  Of the total of 362 persons over 30 years of age examined in Khopasi village of kathmandu (probable glaucoma of 4.7% and definite glaucoma of 1.38%)  Out of 333 persons older than 30 years examined in Ghandruk (established glaucoma 3.3%)
  59. 59. Burden of Blindness – Glaucoma cont..  88,800 Nepalese 30 years and older have definite glaucoma ,  Three times more are glaucoma suspects,  Therefore almost 400,000 Nepalese have definite or probable glaucoma
  60. 60. Burden of Blindness - Trauma • NBS: 8.6/1000 (120,717) have signs and history of trauma, 27% unilaterally, 3% bilaterally blind  Not a major cause of blindness since eye accidents seldom involve both eyes simultaneously.  But a major cause of unilateral blindness.  Second leading cause of blind eyes in Nepal after cataract .
  61. 61. TRAUMA contd…  Risk of trauma to the eye increases with age;  Persons aged 50 years and older have 17.4 times as much trauma blindness as do persons under the age of 15 years.  Penetrating and burn injuries were the type of accident most likely to lead to trauma blindness (occurring in 63% and 10 % of cases, respectively), followed by foreign body (18%) injuries.
  62. 62. Burden of Blindness - Corneal Ulcer  192,000 corneal ulcers every year  526 corneal ulcers every day  11 corneal ulcers every two hours  130 blind eyes due to CU every day
  63. 63. Corneal Ulcer contd….  In the NBS , corneal trauma and ulceration were found to be the second leading cause of unilateral visual loss after cataract,  Accounts for 7.9 % of all blind eyes (Brilliant LB et al, 1985).  Recent evidence suggests, it to be much more common event than previously recognized .  Is a major cause of corneal scarring and visual loss
  64. 64. Corneal Ulcer contd….  The incidence in Nepal is one of the highest reported in the world.  The BES reveals it to be 799 per 100,000 population per year (Upadhyay et al, 2001), which is  seven times higher than in South India (Gonzales CA et al, 1996), and  seventy times greater than reported in the USA (Erie JC et al, 1993).
  65. 65. Burden of Blindness - Diabetic Retinopathy  Prevalence of DM in Gen Pop 20%  Estimated number of diabetics 400,000  Number with Retinopathy 100,000  Estimated Number blind due to DM 30,000  Estimated diabetic blind every year 6,000
  66. 66.  Retinal diseases : Important cause accounting for 3.3% of blindness.(NBS 1981)  In posterior segment disease ,males slightly outnumbered females (58% versus 42%).  More common in age group 50 to 59 years  DR most common posterior segment disease followed by hypertensive retinopathy and vaso occlusive disorder. Analysis of 400 cases of posterior segment diseases visiting retina clinic of Nepal eye hospital Karki DB1 , Malla OK1 , Byanju RN1 , Shrestha S2 Kathmandu University Medical Journal (2003) Vol. 1, No. 3, 161-165
  67. 67. Burden of Blindness - ARMD  With increasing life expectancy ARMD may also be increasing  Gandaki study showed that ARMD affected 8.6% of all blind eyes and was responsible for 10.9 % of bilateral blindness  A study reported 9 ARMD cases in Khopasi ( out of 362) and none at Ghandruk ( out of 333) Age-Related Macular Degeneration in Nepal Kathmandu University Medical Journal9(35):165-9 · July 2011 with 56 Reads
  68. 68. National level Strategy to control Blindness 1.At Primary level-  Location: At HP/SHP level  Primary health care (PHC)personals are trained in primary eye care management .  Deliver health message and treat simple cases  Refer complicated cases to district level hospitals or eye care centers.
  69. 69. 2. Secondary Level  Location: At District Level  Functions:- Preventive, Outreach program Curative: Medical/Surgical Referral
  70. 70. 3.At Tertiary level-  Location: At Zonal Level.  Functions:  Preventive & Outreach programs  Curative: Medical/Surgical  Specialty Services/Lab. Facility  Referral  Maintenance section  Organize regular eye camps in the remote areas.
  71. 71. 4. Institutional Level  Location: At Regional Level  Functions:  Preventive  Curative: Medical/Surgical  Specialty Services : Well Equipped Lab. facilities : Eye Banks : Teaching and Training : Research  These are referral eye hospitals  Have specialty services in various branches of Ophthalmology such as Glaucoma, Retina,Uveitis, Neuro-Ophthalmology, External ocular Diseases etc
  72. 72. Vision 2020 – The Right to Sight Launched in Nepal on November 19,1999 AD  Aim: To eliminate the main causes of avoidable blindness by the year 2020 AD  Mainly focused on Cataract, trachoma, Vitamin A deficiency, Low vision,Glaucoma,Childhood blindness, Diabetic retinopathy etc.
  73. 73. Treatment of Night Blindness(Vitamin A deficiency)  3 doses of 200000 IU of Vitamin A on day 0, 1 and 14  Women of reproductive age with Vit A deficiency- daily dose of 100000 IU orally for 2 weeks  Oral route is preferred  Half the oral dose for intramuscular injection  High protein,high calorie diet supplements of Zn,Fe and Cu.
  74. 74. Prophylaxis of Vit. A deficiency  Health and nutrition education  Vitamin A rich foods  Greens, Spinach ,Palak, Amaranth etc  Carrots, Cabbages, Pumpkin,Papaya,Mangoes  Milk and Fish.
  75. 75. AGE DOSES IInfants less than 6 months 50000 IU orally Infants between 6 months to 1 year year-1 lakh IU orally every 6 months Children between 1 to 6 years 2 lakhs IU orally every 6 months Lactating mothers 200000 IU orally once at delivery WHO prophylaxis against Xerophthalmia (Night Blindness) Vitamin A solution along with measles vaccination.
  76. 76. References  Park’s textbook of preventive and social medicine  Comprehensive Ophthalmology A.K khurana  NNJS 2012  NBS 1981  Midterm Review vision 2020  Internet

Editor's Notes

  • Till date 2010- prevalence is 0.39%
    First survey in 1980/1981- 0.84%,now it is 0.35%(2012 Survey)


  • RAAB focuses on the prevalence of the main causes of
    avoidable blindness in the VISION 2020 programme, like
    cataract, refractive errors , trachoma, onchocerciasis, and
    childhood blindness.

    This is because the aim of VISION 2020: The Right to Sight
    is to eliminate the avoidable blindness by the year 2020

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