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

2. Presentation Layout
Introduction to blindness
Epidemiology
Midterm Review of Vision 2020
Causes of blindness
 Diseases burden
Blindness control

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. 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. 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. 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. 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. 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. 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. 253 million people
are visually impaired
globally 217million have
low vision
36 million are
blind
Fact Sheet N°282 WHO- August 2017

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.  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. 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. 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. 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. 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. Milestones on Eye Care Services
1980: Establishment of HMG/WHO, Prevention
and Control of Blindness project
1981 : National Blindness Survey

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

20. 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.

21. 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)

22.  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.

23. 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

24. What is avoidable blindness?
Blindness that can be treated or prevented
 Cataract
 Glaucoma
 Diabetic retinopathy
 Corneal infections
 Ocular trauma
 Refractive error

25. Situation Analysis
 Overall Blindness Prevalence 0.84
 Male 0.68%
 Female 0.99 %
Male
41%
Female
59%
Gender distributionof blindness

26. 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%

27. 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%

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. Distribution of Blindness PVA
<6/60
0.4% to 0.6%
0.6% to 0.8%
0.8% to 1.0%
>1%

36. 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

37. Cause of Blindness
2012

38. 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%

39. Estimated present Burden of Blindness in
numbers
Assumed prevalence 0.82% (VA<6/60)
 Population base 30,000,000
 Total blind 246,000

40. 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.

41.  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…

42. 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…

44. 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.

45. Burden of blindness -Corneal blindness
 Second leading cause of blindness
Variety of causes :
 Xerophthalmia,
 Trachoma,
 Injuries (accidental, iatrogenic)

46. 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.

47. 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 .

48. 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.)))

49. Trachoma hyperendemic areas of Nepal.

50. 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;

51.  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.

52. 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

53. 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%).

54.  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

55.  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.

57. Burden of Blindness - Childhood Blindness
 1.12/1000 children are blind
 13,200 children are blind
 Seven children become blind every day in Nepal

58. Major cause of childhood
blindness in Nepal
 Vitamin A deficiency
 Trachoma
 Trauma
 ROP
 Congenital cataract
 Congenital glaucoma
 Amblyopia
 Refractive errors

59.  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

60. 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

61. 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%)

62. 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

63. 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 .

64. 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.

65. 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

66. 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

67. 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).

68. 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

69.  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

70. 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

73. 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.

74. 2. Secondary Level
 Location: At District Level
 Functions:-
Preventive, Outreach program
Curative: Medical/Surgical
Referral

75. 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.

76. 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

77. 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.

78. 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.

79. 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.

80. 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.

81. References
 Park’s textbook of preventive and social
medicine
 Comprehensive Ophthalmology A.K khurana
 NNJS 2012
 NBS 1981
 Midterm Review vision 2020
 Internet