Community ophthalmology

COMMUNITY
OPHTHALMOLOGY
Community ophthalmology – use of appropriate strategies and
methods to reduce the burden of eye diseases in a community.
Basic principles –
The practice of community ophthalmology involves –
1. An assessment of the extent of the problem of eye diseases
and socio economic impact of blindness on the community.
2. Finding and applying the most appropiate eye care solutions
fot the specific community.

These solutions comprise of –
a. Preventive activities for control of communicable and non-
communicable eye diseases and environmental health
hazards.
b. Promotive activities concerned with improved nutrition,
intensive eye health education and improved life style.
c. Curative programs addressing the common eye conditions
like refractive errors , trachoma, cataract, xerophthalmia etc.

BLINDNESS
ECONOMIC BLINDNESS – that level of blindness which
prevents an individual from earning his wages.
Presenting vision <6/60 in the better eye.
Since this level of visual impairment hinders a person from
earning – also referred as WORK VISION
LEGAL BLINDNESS – The level of blindness that necessitates
welfare measure and legal protection.
Vision less than 6/60 or 20/200 or less in the better eye , with
correction, and/or a visual field less than 10 degrees.
This definition is used in USA.

SOCIAL BLINDNESS – the degree of disability that hampers an
individual from socially interacting with the family and peer groups
in a satisfactory manner.
The inability to count fingers at a distance of 3m (with the better
eye) with best correction.
Since this level of visual impairment curtails the day to day
movement of an individual – also referred as WALK VISION.
MANIFEST BLINDNESS – V.A < 1/60 .
Seriously constraints the accomplishment of tasks for daily living .
Also impairs mobility. Used as service indicator – as most of the
cataract blind in the developing world are operated at this stage.

ABSOLUTE BLINDNESS – the inabilty to perceive light in any
eye.
CURABLE BLINDNESS – that stage of blindness where damage
is reversible by prompt management. E.g cataract
PREVENTABLE BLINDNESS- the loss of blindness that could
have been completely prevented by institution of effective
preventive or prophylactic measures .e.g xerophthalmia,
trachoma, glaucoma
AVOIDABLE BLINDNESS – the sum total of curable blindness. In
India, 85-90% of all blindness is avoidable.
INCURABLE BLINDNESS – the state of blindness which is
beyond redemption. 5-10%

W.H.O – accepts a cut off of V.A<3/60 in the better eye, with
best possible correction to define blindness.
N.P.C.B – V.A<6/60 in the better eye with best possible
correction to define blindness.

N.P.C.B
THE NATIONAL PROGRAMME FOR CONTROL OF
BLINDNESS
- Was launched in 1976.
- Being implemented as 100% centrally sponsored programme
since its inception.
- In 1982, it was implemented in the prime minister’s 20 point
socio economic programme.

Overall objectives are –
- Provision of comprehensive eye care facilities at primary,
secondary and tertiary health care level.
- To achieve a substantial reduction in the prevalence of eye
diseases in general and the overall reduction in the prevalence
of blindness to 0.3% by 2000 AD

COMPONENT ACTIVITIES UNDER N.P.C.B –
- Creating an infrastructure for cataract surgical and support
services.
- School eye screening and refraction services.
- Strengthening eye health education activities
- Control of corneal blindness including establishment of eye
banks.

As per Survey in 2001-02, prevalence of blindness is estimated to
be 1.1%.
Rapid Survey on Avoidable Blindness conducted under NPCB
during 2006-07 showed reduction in the prevalence of blindness
from 1.1% (2001-02) to 1% (2006-07).
Various activities/initiatives undertaken during the Five Year
Plans under NPCB are targeted towards achieving the goal of
reducing the prevalence of blindness to 0.3% by the year 2020

Main causes of blindness are as follows: -
Cataract (62.6%)
Refractive Error (19.70%)
Corneal Blindness (0.90%)
Glaucoma (5.80%)
Surgical Complication (1.20%)
Posterior Capsular Opacification (0.90%)
Posterior Segment Disorder (4.70%)
Others (4.19%)
Estimated National Prevalence of Childhood Blindness /Low Vision is
0.80 per thousand

Goals & Objectives of NPCB in the XII Plan
· To reduce the backlog of blindness through identification and
treatment of blind at primary, secondary and tertiary levels based
on assessment of the overall burden of visual impairment in the
country.
· Develop and strengthen the strategy of NPCB for “Eye Health”
and prevention of visual impairment; through provision of
comprehensive eye care services and quality service delivery.
· Strengthening and upgradation of RIOs to become centre of
excellence in various sub-specialities of ophthalmology

. Strengthening the existing and developing additional human
resources and infrastructure facilities for providing high quality
comprehensive Eye Care in all Districts of the country;
· To enhance community awareness on eye care and lay stress
on preventive measures;
· Increase and expand research for prevention of blindness and
visual impairment
· To secure participation of Voluntary Organizations/Private
Practitioners in eye Care

Three major types of refractive corrective which is to be provided
to the population –
- Myopic correction for school children
- Presbyopic correction to the above 40 years segment
- Aphakic correction to operated cataract patients.
- INTENSIVE HEALTH EDUCATION ACTIVITIES – are central
to the success of the N.P.C.B
- Information, education and communication activities have
recently been augmented.

CORNEAL BLINDNESS AND EYE DONATION – for this purpose
N.P.C.B supports the establishment of eye collection centres and
eye banks both in the government and the NGO sector.
WORLD BANK ASSISTED CATARACT CONTROL PROJECT –
- Was initiated in 1994
- Covers 7 states where the prevalence of blindness and the
backlog of operable cataracts was the highest in the country –
U.P, Rajasthan, M.P, Maharashtra, A.P, Orissa and Tamil Nadu.
- In these states over a period of 7 years (1994-2001)
augmentation of cataract services was attempted.
- 11 million cataract surgeries were planned to be done.

DANIDA SUPPORT TO THE NATIONAL PROGRAMME – the
Danish international development agency has been assisting
NPCB since 1978.
- The DBCS concept was first successfully tried out by DANIDA.
- Vision screening and programmes in schools have also been
pioneered by DANIDA
- In the current phase of assistance, DANIDA has adopted
Karnataka as a pilot state and is funding all eye care activities
in this state.
- Phase III of the DANIDA assistance is being implemented
since 1997.

DFID ASSISTANCE TO NPCB – the department for International
Development of the U.K has been actively collaborating with the
Govt. of India in strenghthening Community Ophthalmology
services in India.

ORGANIZATION OF NPCB –
1.National programme management cell
2. State programme management cell
3. District blindness control
a. District hospital ( Medical Superintendent)
i. Ophthalmic surgeon
ii. District mobile unit
b. District health officer(C.M.O)
i. Community health officer – medical officer – MPW
ii. Primary health officer – medical officer - MPW

VISION 2020: THE
RIGHT TO SIGHT
- Global initiative launched by the World Health Organization and
a Task Force of International Non-governmental Organizations.
To combat the gigantic problem of blindness in the world.
- It was launched in Geneva on February 18, 1999 by the then
Director General of the World Health Organization, Dr. Gro
Harlem Brundtland.

- envisages collaboration between governments, World Health
Organization, International Agency for -
Prevention of Blindness, funding agencies, international,
nongovernmental and private organizations that collaborate with
the World Health Organization in the prevention and control of
blindness.

Globally, five conditions have been identified for immediate
attention for achieving the goals of Vision 2020
They are-.
- Cataract
- Trachoma
- Onchocerciasis
- Childhood blindness
- Refractive Errors and Low Vision

These conditions have been chosen on the basis of-
1. their contribution to the burden of blindness
2. the feasibility and affordability of interventions to control
them.
Each country will decide on its priorities based on the magnitude
of specific blinding conditions in that country.

Under this initiative, five basic strategies to combat blindness are-
.
1. Disease prevention and control
2. Training of personnel
3. Strengthening the existing eye care infrastructure
4. Use of appropriate and affordable technology
5. Mobilization of resources

Cataract
- Major cause of blindness in the world
- An estimated 16-20 million people are bilaterally blind from
cataract and the number is increasing.
- Cataract surgical rate - a quantifiable measure of the delivery of
cataract services.
- Number of cataract operations per million population per year.
- Meaningful to estimate only when there is ample information on
all cataract surgery performed in a country, for example including
the private sector.

Aim
Elimination of cataract blindness (person with vision less than
3/60 in both eyes)

Targets
Global cataract prevalence targets 1990-2020
Year Populati
on
Projecte
d no.
cataract
blind at
1995
service
of
cataract
level
No.
cataract
blind
(millions)
Target
Prevalen
ce
blindnes
s
1990 5400 16.0 16.0 0.3
1995 5700 20.0 20.0 0.35
2000 6100 25.0 15.0 0.25
2010 6800 35.0 7.0 0.10

Global Cataract Surgical Rate Targets 1995-2020
Year Global cataract
surgical rate
Global no. of
cataract
operations
1995 1100 7.0
2000 2000 12.0
2010 3000 20.0
2020 4000 32.0

Trachoma
An estimated 146 million people have the active infection with the
microorganism Chlamydia trachomatis, for which antibiotic
treatment is indicated.
- There are approximately 10.6 million adults with in turned
eyelashes (trichiasis/entropion), for which eyelid surgery is
needed to prevent blindness.

- An estimated 5.9 million adults are blind from corneal scarring
due to trachoma.
- Trachoma is the second cause of blindness in
sub-Saharan Africa, China and the Middle-Eastern countries.
- Trachoma is to be controlled through the implementation of the
SAFE strategy integrated within primary health care in all
communities identified as having blinding trachoma within a
country.

This includes the following:
i) Assessment to identify communities with blinding trachoma.
ii) Delivery of community-based trichiasis .Surgery by trained paramedical
staff (S of SAFE).
iii) Antibiotic treatment (either tetracycline eye ointment or oral
azithromycin) for children with active disease (A of SAFE).
iv) Promotion of Facial cleanliness (F of SAFE) and Environmental
improvement
(E of SAFE), including personal hygiene and community
sanitation as part of primary health care.
Aim
Elimination of blindness due to trachoma

Targets
Global Trachoma Targets for Cases of Trichiasis and Active
Infection

Onchocerciasis
- An estimated 17 million people are infected with onchocerciasis.
- Approximately 0.3-0.6 million are blind from the disease.
- Endemic in 30 countries of Africa and occurs in a few foci in six
Latin American countries and in Yemen.
Aim
Elimination of blindness due to onchocerciasis.

Childhood Blindness
- Estimated 1.5 million blind children in the world, of whom
1 million live in Asia and 3,00,000 in Africa.
- Prevalence = 0.5 - 1 per 1,000 children aged 0-15 years.
- An estimated 5,00,000 children going blind each year (one per
minute).
- Many of these children die in childhood.
- It is estimated that childhood blindness causes 75 million blind
years (number blind x length of life), second only to cataract.

The causes of childhood blindness vary from place to place and
change over time.
Aim
To eliminate avoidable causes of childhood blindness.

Place Major causes of childhood
blindness
Africa - Corneal ulcer/scar (measles,
vitamin A
deficiency and harmful traditional
practices)
- Congenital cataract
- Hereditary disorders
Asia - Vitamin A deficiency
- Congenital cataract / rubella
- Hereditary retinal diseases
Latin America - Congenital cataract and glaucoma
rubella
- Retinopathy of prematurity
Industrialized countries and urban
centres
- Retinopathy of prematurity
- Congenital cataract
- Hereditary disorders

Vitamin A deficiency
Aim
To achieve and sustain the elimination of blindness due to vitamin
A deficiency.

Surgically avoidable causes
Aim
To control blindness in children from cataract, glaucoma and
retinopathy of prematurity (ROP).

Refractive Errors and Low Vision
- Spectacles are an essential part of the treatment of many eye
patients.
- Their provision is therefore an integral part of eye care delivery.
The steps in the provision of refraction services and low vision
care for patients are as follows-.
i) Screening - Identification of individuals with poor vision which
can be improved by spectacles or other optical devices.
ii) Refraction - Evaluation of the patient to determine what
spectacles or device may be required.

iii) Manufacture - Manufacture of the spectacles or an appropriate
device, both of which may be manufactured locally, purchased
externally,or donated.
iv) Dispensing - Issuing of the spectacles or device, ensuring a
good fit of the correct prescription.
v) Follow-up - Repair of spectacles/devices or repeat dispensing.

Aim
Elimination of visual impairment (vision less than 6/18) and
blindness due to refractive errors or other causes of low vision
This aim goes beyond the elimination of blindness and also
includes the provision of services for individuals with low vision.

Human Resource Development
Community Level
Primary Health Care (PHC) is a fundamental concept of the World
Health Organization for improvement in health.
All the elements of primary health care can contribute to the
prevention of blindness.
PHC worker - important role to play in the control of blindness -
i) Identification - PHC workers are ideally placed to identify blind
and
visually disabled children and adults in their own home.

ii) Assessment and diagnosis - PHC workers can be taught to
assess those individuals who could be helped by the services of a
specialist, for example identifying cataract for referral to an
ophthalmologist.
iii) Referral for management and treatment - PHC workers can
encourage individuals to go for treatment and can provide the
referral system that will promote this.
iv) Follow-up and evaluation - After treatment, the PHC worker
can follow up the patient at home to help with visual rehabilitation
(the patient after cataract surgery, for example), give advice on
any treatment and make sure that spectacles are available.

Secondary and Tertiary Levels
Ophthalmologists –
target 2000 2010 2020
Ophthalmolo
gists per
population
Sub-
Saharan
Africa
500000 1:400000 1:250000
Asia 1:200000 1:100000 1:50000

Vision 2020: The Right to Sight in India
- India was the first country in the world to launch the National
Programme for Control of Blindness in 1976 with the goal of
reducing the prevalence of blindness.
- Of the total estimated 45 million blind persons (best
corrected visual acuity < 3/60) in the world, 7 million are in India
.

- Due to the large population base and increased life
expectancy, the number of blind particularly due to age-related
disorders like cataract, is expected to increase.
-India is committed to reduce the burden of avoidable blindness
by the year 2020 by adopting strategies advocated for Vision
2020- The Right to Sight.

Current Status
Extent of the problem
Three major surveys have been conducted to find out the
prevalence of blindness in the country.
- The first survey- undertaken by the Indian Council of Medical
Research (ICMR) in 1974 indicated a prevalence rate of 1.38% in
the general population (Visual acuity < 6/60).
- Second survey - sponsored by the Government of India/World
Health Organization (1986-89), the prevalence rate increased to
1.49% (presenting visual acuity< 6/60 in the better eye).

As per information available from various studies:
estimated 12 million bilaterally blind persons in India with
visual acuity less than 6/60 in the better eye, of which nearly 7
million have visual acuity less than 3/60 in the better eye
(presenting vision).
Recent survey (1999-2001) in 15 districts of the country-
indicated 8.5% of population aged 50+ years is blind (visual acuity
< 6/60).

Main causes of blindness in 50+ population are as follows:-
Cataract 62.6%
1 Refractive Errors 19.7%
2 Corneal
Blindness
0.9%
3 Glaucoma 5.8%
4 Surgical
Complications
1.2%
5 Posterior
Segment
Disorders
4.7%
6 Others 5.0%

- No nationwide reliable data on refractive errors and low
vision in the country except some isolated studies
- A survey in Delhi, to assess the prevalence and causes of
blindness and low vision in children aged 5-15 years- indicated
that 1 % of children in this age group had vision < 6/18 in the
better eye.

Achievements
- All surveys indicated cataract as the single largest cause of
blindness in India.
- Controlling cataract blindness- given priority in India.
- Funds were mobilized from the World Bank during 1994-2002. -
- Assistance was provided to seven major states, estimated to
contribute 70% of the country’s cataract blind.

Under this project, following have been the achievements -
1.307 dedicated eye operation theatres and eye wards
constructed in district level hospitals
2.Supply of ophthalmic equipment for diagnosis and treatment of
common eye disorders, particularly for intra-ocular lens (IOL)
implantation at all district hospitals
3.More than 800 eye surgeons trained in IOL surgery
4. 30 non-governmental organizations (NGOS) assisted for setting
up/ expanding eye care facilities

5. Volume of cataract surgery has steadily increased since 1993.
Cataract Surgery Rate is 3800 per million population (2003-04).
There has been a significant increase in proportion of cataract
surgeries with IOL implantation from <5% in 1994 to 85% in 2003-
04.
- There has also been an increase in coverage of eye care
services
- A Rapid Assessment survey carried out in 14 districts in 1998
indicated coverage of 70% persons having access to eye care
services.

Decentralized Approach
India is a vast country having 28 States and 7 Union Territories
with 593 districts, with an average population of nearly two million
per district.
The programme implementation has been decentralized upto the
district level where District Blindness Control Societies (DBCS)
have been set up as the nodal agencies.
Members of the DBCS include officials from District
Administration, Health, Education and Social Welfare
Departments, media, community leaders and NGOs/Private
Sectors involved in eye care.

These societies directly receive funds from the Government.
The concept is to establish a bottom up approach in dealing with
blindness through multi sectoral and coordinated efforts.
These societies are responsible for identifying blind in every
village, organize diagnostic screening camps at suitable locations,
arrange transportation of patients to the designated facilities, and
ensure follow up.

1.Monitoring and Evaluation
Following tools have been developed for effective monitoring of
the programme:
- Standard prototypes for reporting of performance and
expenditure by District Blindness Control Societies;
- Standard Cataract Surgery Records & Patient’s Discharge
Cards
- Standard Referral Card for children having refractive errors;
- Specific software to facilitate computerized MIS at various levels.

2. Sentinel Surveillance Units (25) - set up in the Departments
of Ophthalmology and Preventive and Social Medicine in Medical
Colleges for:
a. assessment of beneficiary profile
b. visual outcomes based on cataract surgical records and follow-
up of a sub-sample of operated cases to assess visual outcomes.
c. Ocular morbidity data also collected to assess patterns and
trends of eye disease.

3.National Surveillance Unit - established in the Department of
Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, New Delhi.
Functions of this unit –
a. Establishing a database for all blindness
control activities in India
b. Providing technical support for the network of Sentinel Surveillance Units
established in the country
c. Disseminating information on trends in blindness control activities in the
country,
d. Developing information resources and relevant software
packages for monitoring and evaluation of programme implementation
including mapping of services for end-users, etc.

4.Independent studies have been undertaken to evaluate the
programme activities. These include:
1. Communication Needs Assessment;
2. Beneficiaries Assessment;
3. Evaluation of trained eye surgeons;
4.Rapid Assessment for estimation of prevalence, coverage and
outcome;
5. Epidemiological survey on blindness in population aged 50+
years in 15 districts.

Quality of Services
-substantial efforts have been made by discouraging outdoor
surgical camps
-emphasis on IOL implantation at institutional level
-emphasizing follow up of operated cases and greater coverage
for women and underprivileged sections of the society.

The programme is being implemented in collaboration with
centres of excellence in the Government and Non-Government
sectors which have emerged as leading training and research
institutions capable of taking a leadership role for shaping eye
care programme not only in India, but in other countries as well.
- These institutions have excellent infrastructure, human
resources and patient volume required for imparting training and
conducting research.
- There is close coordination, formal or informal, between
these institutions in the country.

Situational Analysis of Eye Care Infrastructure and Human
Resources
- Situational Analysis of Eye Care Infrastructure and Human
Resources in India - conducted by the Ophthalmology Section of
Directorate General of Health Services, Ministry of Health and
Family Welfare, Government of India and Dr. R. P. Centre for
Ophthalmic Sciences in 2002-03.
An attempt was made to collect information on infrastructure
and human resources for training as well as service delivery in
the whole country.

Data was collected from two different sources:
1. Teaching institutions for assessing the status of ophthalmology
training;
2.District Blindness Control Societies for assessing infrastructure
foreye care service delivery in districts.
These data were supplemented by other sources like MIS data
base and private hospitals.

Performance of Cataract and Other eye Surgeries
ECCE/IOL was the commonest procedure for Cataract Surgery.
Phacoemulsification and Small Incision Cataract Surgery are
gradually being performed on more patients.
- Other surgeries performed in medical colleges
are 1.trabeculectomy
2. Squint
3.Keratoplasty
4. vitreo-retinal surgery and
5.DCR/DCT.

Mean number of ECCE/IOL per medical college per year -1215
operations.
On an average, 866 other eye operations were performed
per medical college per year.
Ophthalmic Equipment
Most of the colleges had all equipment related to cataract surgery,
but they were not fully equipped for managing other eye diseases
particularly posterior segment disorders.

Eye Care Facilities and Human Resources
- 47% of all eye care facilities are in the Private Sector
- 49% of all eye beds are in voluntary sector.
- Government sector contributed 33% of facilities and 28% of
eye beds.
- 37% of eye surgeonswere employed in the Government Sector
and the rest were evenly distributed in Private and Voluntary
Sector.
- Wide inter-state variation in eye care facilities and human
resources was observed in the study.

Vision 2020: The Right to Sight was launched in India on October
10-13, 2001 at Goa.
- A Working Group was constituted by the Government
of India for preparing the Plan of Action and Strategies on “Vision
2020-The Right to Sight” initiative in India.
-The Working Group met at Manesarand Lucknow to develop the
Plan of Action.
-The Draft Plan of Action was submitted by the Working Group to
the Ministry of Health and Family Welfare in August 2002.
-This was approved in principle as a document for future planning
of National Programme for Control of Blindness in India.

The target diseases identified for Vision 2020 in India
include:
1. Cataract
2. Childhood Blindness
3. Refractive Errors and Low Vision
4. Corneal Blindness
5. Diabetic Retinopathy
6. Glaucoma
7.Trachoma (focal)

Human Resource Needs
-There is a need to develop 2000 Service Centres -
each with 2 ophthalmic surgeons and 8 ophthalmic
paramedics (hospital).
-20,000 Vision Centres need to be developed, each
with one Ophthalmic Assistant (Community) or
equivalent.
-Eye Care Managers will be required at the Service
Centers.
-Community Eye Health Specialists will be required at
the Training Centres.

Paramedics
- Mid Level Eye Care Personnel.
Two streams of such personnel are envisaged:
1. Hospital based - all categories like nurses, refractionists,
ophthalmic technicians / assistants, theatre personnel, etc.
2.Community / Vision Centre based - these persons will be
responsible for school eye screening, refraction, primary eye care,
tonometry, etc.

Objectives for the year 2002-2007
1. To improve the quantity &quality of cataract surgery.
2. Development of pediatric ophthalmology departments in training
centres and centres of excellence.
3. To screen known diabetics for D.R in clinics and to screen >35
years attending the clinic.
4. Low vision services to be initiated at tertiary level with adequate
linkages with secondary level and with primary care in a phased
manner.
5. Development of safe eye banks and networking of eye donation
and training centres.
6. Integration of primary eye care with primary health care
throughout the country by training MO and OA and other para
professional staff.

Eye Care Infrastructure
Centre’s of Excellence (20)
Training Centres (200)
Service Centres (2000)
Primary Level Vision Centres (20000)
The infrastructure pyramid given above is based on the structure recommended
by the World Health Organization.

Under the National Programme for Control of Blindness, a
Conference on Primary Eye Care to support Vision 2020 was
held on April 11 -14, 2002 at Coimbatore.
The participants included the members of the Working Group and
experts in the field of primary eye care in India.
The recommendations of this meeting focused on:
1. Infrastructure and support for Primary Eye Care
2. Human Resource Development and Training Needs
3. Models for Service Delivery and Community Participation.

A. Infrastructure & Support for Primary Eye Care
1. Vision Centre
Vision centres - Primary Eye Care to a population of 50,000 in the
rural areas.
- Primary Health Centres
- Cooperatives manned by Middle Level Ophthalmic Personnel
(MLOP).
The target - post one Middle Level Ophthalmic Personnel(MLOP)
per 50,000 population throughout the country by 2020.

2. Functions of Vision Centre
a. Identification and Referral of minor external eye diseases e.g.
Conjunctivitis, Eye Injuries etc.;
b. Vision testing and prescription / dispensing of glasses;
c. School Eye Screening programme;
d. Eye health education;
e.Training of volunteers;
f. Identification / referral of Cataract, Glaucoma etc. to service
centres.

3. Personnel For Primary Eye Care (PEC).
To deliver PEC, following personnel need to be involved:
1.Area specific involvement of volunteers from the local
community/ NGOs;
2. Two teachers from each middle school;
3. Health workers posted at sub-centers and PHC;
4. Middle Level Ophthalmic Personnel (MLOP);
5. Medical officers at P.H.C.s and General Practitioners.

4. Examination Process
Facilities for following examinations need to be made available at
each
vision center to carry out functions of PEC:
-Torch light examination with the assistance of magnifying loupe;
- Retinoscopy, including cycloplegic refraction;
- Schiotz tonometry;
- Fundus examination by medical officers (dilated pupil).
5. Support
National Programme for Control of Blindness should provide
following assistance to develop PEC facilities:

a. Equipment at Vision Centre:
1. Trial Set
2. Trial Frame (Adult and Child)
3. Vision Testing Drum
4. Plane Mirror Retinoscope
5. Streak Retinoscope
6. Snellen’s Charts

7.Binomag / Magnifying Loupe
8. Schiotz Tonometer
9. Torch (with batteries)
10. Lid Speculum
11. Epilation Forceps
12. Foreign body spud and needle
13. Direct Ophthalmoscope (for use by Medical Officers)
14. Rechargeable Batteries

b. Drugs
1. Cyclopentolate Eye Drops
2. Tropicamide Eye Drops
3. 4% Xylocaine Eye Drops
4.Ciprofloxacin Eye Drops
5. Chloramphenicol Eye Drops
6. 1% Tetracycline Eye Ointment
7. Ciprofloxacin Eye Ointment
8. Neosporin Eye Ointment
9. Artificial Tears
10. Oral Vitamin ‘A’ Solution and Capsules

Materials
1. Blindness Registers (For Village Surveys)
2. Referral Cards for patients needing further evaluation of PHC
3. Vision card with prescription for spectacles
4. Flip Book for Eye Health Education
5. Charts and Posters
6. Do-it-yourself Vision Testing Posters
7. Cataract Card for Health Workers

Spectacles
Free / Subsidy for Spectacles for
1. Children (5-15 years)
2. Aphakic Patients

B. Human Resource Development and Training Needs
Personnel to be trained in Primary Eye Care:
a. Medical Officers at PHCs
b. Staff at PHC/Sub centers
c. School teachers
d. Village level volunteers

Training needs assessment should be carried out after defining job
responsibilities of above personnel.
- Village level activities could be contracted to local NGOs / self help
groups and this would allow decentralization to become a reality and
it would be a sustainable model. This could include optical
cooperative units.
It is proposed to develop mobile primary eye care kit for the health
workers / volunteers. The kit may contain-.
a. Simple questionnaire on PEC
b. Common eye ailments
c. Simple tips on how to deal with these ailments

Eye Care Education
Eye care education should target the following
a. Mothers regarding hygiene, nutrition, prevention of injuries;
b. Children regarding good reading habits, safety at play;
c. Teachers regarding identification of symptoms using simple
checklist.
Training
Training on PEC should include:
a. DRIP Training:-
One hour thematic training at PHC for transfer of skills related to
Primary Eye Care for Health Workers/ Village level volunteers.

b. Cascading training
-Training to function as a team. Training of teachers should
include refractive errors and common eye symptoms, do’s and
don’t’s.
-Training of VHW should include skills for vision testing, diagnosis
of operable cataracts, monitoring use of spectacles.

- Need to develop modules for training different functionaries;
- Orientation of indigenous practitioners in modern management
should be undertaken for corneal ulcers, conjunctivitis and dangers
of harmful traditional medicines. The training should include
recognition of sight-threatening symptoms and referral system;
- Need to augment training capacity for Mid Level Ophthalmic
Personnel;
- Mechanisms for monitoring should be developed to assess the
effectiveness of training at various levels;
- Referral and support system should be developed to link PEC
to secondary & tertiary levels
c. Models for Service Delivery and Community Participation.

Childhood Blindness:
- “Pediatric Ophthalmology Facility” should be developed at Tertiary
Level.
- Existing eye surgeons need to be trained in Pediatric
ophthalmology.
There may not be a need to create separate post of pediatric
ophthalmologists at this point of time.
- Training of Ophthalmic Surgeons in Pediatric Ophthalmology for a
minimum of 6 months at identified tertiary eye care centres.
- Support development of Pediatric ophthalmology Team ( including
Pediatrician, Anesthetist, MLOPs)

- In case a hospital is already doing Pediatric Ophthalmic surgeries,
some support systems may be required to develop Pediatric Ophthalmology
Facility.
- Equipment required for Pediatric Ophthalmology need to be provided.
- Depending on the volume of Pediatric Ophthalmic Surgery, decision
regarding setting up of a dedicated pediatric OT or providing adequate
O.T time may be taken.
- As more than half (57%) of childhood Blindness is avoidable, emphasis
should be given to prevent Childhood Blindness through cost effective
strategies.

Low Vision & Refractive Errors:
- Refractive Errors screening within a specified period of admission
toschools should be done by schools in collaboration with District
Blindness Control Society / District Education Department.
- Address the organised sectors initially for screening and managing
Presbyopia.
- Screening and services for refractive errors / low vision should be
integrated with cataract screening programme.
- Constitute a Task force to develop strategies for Low Vision
services.

Corneal Blindness:
- Emphasis on Hospital Retrieval System to get better donor
material.
- There is an urgent need for assessment of number of people
who would benefit by corneal grafting.
- For vitamin A supplementation, we should focus on areas that
are economically backward. Priority should be given to slum
populations,tribal regions, drought and flood prone areas and
migrant populations.

Posterior Segment Disorders:
- Medical Retina Services need to be developed in tertiary eye
care institutions.
These units shall attend to various posterior segment disorders,
primarily, diabetic retinopathy.
- Awareness about diabetic retinopathy should be created in
clinics
managing diabetic patients.
- A small pamphlet on Diabetic Retinopathy needs to be
developed for the physicians.

-Some inexpensive screening mechanisms for diabetic retinopathy
should be established at the diabetic clinics. On a pilot basis, fundus
cameras can be introduced in some clinics that are located centrally
where diabetics can be invited to have free fundus photographs
taken.
- Patients of age-related macular degeneration need low vision
services.
Linkage needs to be established between the medical retina services
and the low vision services.

Advocacy & Public Awareness:
- Various guidelines and training manuals need to be made
available on the MOHFW website.
- Advocacy workshops should be organized involving the
ophthalmologists and communication experts.
Annual Plan should list specific time bound activities for advocac
Trachoma:
Information on Surgery for entropion and trichiasis should be
collected from endemic areas to assess current situation.

Human Resource Development:
- Ophthalmology as a separate subject in MBBS course;
- Interaction with Universities through Medical Council of India for
uniform system for Ophthalmology as separate subject, common
curriculum, evaluation;
- Increase in number of eye surgeons- MS/ Primary DNB slots;
- Continued professional improvement through CME for eye
surgeons and MLOPs and fellowship courses in super specialties
for ophthalmologists;

- Desired ratio of Ophthalmologist- MLOPs in hospitals should be
1:3 to 1:4; (MLOPs include dedicated Ophthalmic paramedics and
Nurses in Ophthalmology Departments);
- Explore feasibility of 3 month resident exchange programme at
selected institutes during final year of PG course.

Data base on Eye Care Infrastructure & Human resources:
- Dissemination of Report to all Stakeholders / States for use in
identifying under-served areas
- Periodic update of data + Strengthening of Surveillance
Network

Community ophthalmology

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