Optometry in Developing Countries

Even though the treatment of refractive error is simple and successful, the condition is still responsible for a significant amount of blindness in both developing and developed countries. The burden of blindness due to refractive error, in terms of blind-person-years, is even more significant than the numbers indicate since refractive error blindness mostly starts at a young age and causes significant economic and social burden to societies.^1–7

Refractive errors are a priority within the global initiative for the elimination of avoidable blindness, VISION 2020: The Right to Sight. Until recently, refractive errors never figured as a cause of vision impairment or blindness in the surveys; this was probably due to the World Health Organization's (WHO) categorization of visual acuity as based on best corrected vision, presumably because of the ease (from a technical perspective) with which it can be addressed. Thus, refractive errors had not attracted the attention of policymakers and service providers.

According to WHO, “A total of 153 million people (range of uncertainty: 123 million to 184 million) are estimated to be visually impaired from uncorrected refractive errors, of whom eight million are blind. This cause of visual impairment has been overlooked in previous estimates that were based on best-corrected vision. Combined with the 161 million people visually impaired estimated in 2002 according to best-corrected vision, 314 million people are visually impaired from all causes: uncorrected refractive errors become the main cause of low vision and the second cause of blindness.”⁸

Table 1 summarizes the prevalence of refractive error findings from published studies in different WHO regions. It shows widely varying estimates and illustrates the difficulty in making meaningful comparisons.⁹ Although measurement methods are not identified in the table, either auto-refraction or retinoscopy, frequently with cycloplegia for younger ages, was commonly used. Data generally pertain to measurements in the right eye. Considering myopia and hyperopia together, nearly 100% of some age groups were affected by refractive error in a few of the studies.

TABLE 1: Prevalence of refractive error

Against this background of a huge unmet need, the availability of services is limited and human resources scarce, particularly in the developing countries. These issues are being addressed in the context of Vision 2020: The Right to Sight, which has prioritized refractive errors and low vision for interventions. Over the last ten years, concerted efforts have been made to address this issue of refractive errors and low vision, and people have transcended their professional boundaries to come together to address these issues. Although, there are a number of initiatives and examples of this happening across the world, I choose to focus on initiatives where I had some personal involvement.

Optometry Giving Sight (OGS).

Optometry Giving Sight is a joint initiative of the World Optometry Foundation (WOF), the International Centre for Eyecare Education (ICEE), and the International Agency for the Prevention of Blindness (IAPB) and supports the goals of VISION 2020: The Right to Sight, an initiative of IAPB and WHO. OGS was established in 2003 to address the needs of the 250 million men, women, and children around the world who are blind or visually impaired simply because they do not have access to an eye exam and a pair of glasses. OGS is raising funds to support a number of initiatives to address the issue of uncorrected refractive errors.

Giving Sight to Blind Children.

Sightsavers International has been supporting the education programs for children with visual impairment in East Africa for nearly 30 years. A rapid assessment of children in an integrated education program in Malawi in 2005 revealed that a number of children attending education through Braille could be corrected with a pair of glasses (unpublished data). Another significant proportion could manage well with simple low vision devices. In light of these findings, it was decided by Sightsavers International to carry out a comprehensive and complete assessment of all the children enrolled in various integrated education programs for children with visual impairment throughout East Africa.

The number of children enrolled in the Inclusive Education (IE) program in Malawi, Kenya, Tanzania, and Uganda is 4465. As part of this exercise, a total of 3656 children were comprehensively assessed clinically and all those who could benefit from any form of treatment i.e., cataract surgery, refractive correction, or low vision devices were either provided with these or referred to the appropriate service providers. The exercise in Malawi was carried out by the national focal persons for low vision and supervised by Hasan Minto, Ian Bailey, and Jill Keeffe. The exercise in Kenya was carried out by the Kenyan focal persons trained in low vision in Durban. The exercise in Uganda was carried out by national focal persons and a team of optometrists and ophthalmologists. The exercise in Tanzania was carried out by local optometrist and OCOs. I supervised and provided support for all these assessments. The key findings of this exercise are seen in Table 2.

TABLE 2: Clinical assessment of East African children enrolled in IE program supported by Sightsavers International

This exercise also led to a strong realization that quality education support cannot be achieved without effective collaboration with health care, in general, and eye care, in particular, and determined the need to establish a regional school of optometry which could produce enough Optometrists who could offer quality refractive and LV services. As a result, the development of regional school of optometry in Malawi is in progress with the support of Sightsavers International, CBM, and ICEE.

Figure: Optometrist conducting low vision assessment in Uganda. Photo: Courtesy Hasan Minto.

Development of Optometry Schools in Africa.

There is a severe shortage of trained human resources to provide refractive services in Africa. The majority of the optometry training programs and optometrists are based in Nigeria, South Africa, Tanzania, and Sudan but even in these countries most are working in the private sector and in the big cities, providing little assistance to the vast numbers in rural areas and smaller cities. However, in the last 5 years a number of initiatives have been launched and supported by major INGOs (International Non-Government Organizations) to address this issue. As a result, optometry schools have been established in Ghana and Ethiopia, and efforts are underway to establish optometry training programs in Gambia, Kenya, Malawi, Mali, Uganda, and Mozambique. These training programs will have significant impact to address the shortage of human resources and establishing the optometry profession as part of comprehensive eye care team.¹⁰

Establishment of Optical Centers in West Africa.

The project was implemented by Sightsavers in 2005 as a regional initiative to resolve the continuing problem of a lack of access to affordable optical services across West Africa. While the idea of providing optical services has been discussed as an important aspect of service delivery, few countries in the region have been proactive about their set up and operation. The goal of the project is to fast-track the set up of optical centers, within eye care projects across the region, and also allow for the expansion of these services to incorporate low vision assessments and service. As a result, 12 optical centers have now been set up in Ghana, Cameroon, Mali, Gambia, and Sierra Leone to provide refractive, optical, and low vision services to some of the most under-served communities in the world.

Regional Refractionist Training Programme in Guyana.

Guyana is one of the poorest countries in South America. Access to refractive and low vision services in the public sector was non-existent. A regional refractionist training program with support from the Caribbean Council for the Blind is developing human resources for refraction and low vision. Students from various Caribbean countries are taking this refractionist training program. Refraction, low vision, and optical services have been integrated into eye care at the public hospitals where these are available and accessible to the people.

Establishment of Global Resource Centre (GRC).

Technology to deliver refractive and optical services has under-gone a revolutionary change by the establishment of a Global Resource Centre at International Centre for Eyecare Education in Durban, South Africa. The GRC is an initiative where three INGOs (SSI, CBM, ICEE) have pooled resources to develop a network for procurement of high quality optical supplies and refraction equipment and making it available to various programs in not for profit sector. This has helped in tremendously reducing the costs, thus, making spectacles affordable to the vast majority across the developing world.

Human Resource Development Program and Low Vision Services in Pakistan.

Prior to 1996, no optometry training program existed in Pakistan. The first training program in refraction was launched at Pakistan Institute of Ophthalmology as a 1-year program. Since then, this training has evolved and five institutions are offering a 4-year optometry training program leading to a university degree. The graduates of these programs have started serving in the public sector and are bringing about a major change in availability of refractive, low vision and optical services.

The National Low Vision (NLV) program started in 1996 with the support of Sightsavers International with the overall aim to develop low vision services as part of eye care and create the necessary linkages with other services, including education, rehabilitation, and social services. The NLV program focuses on service delivery, human resource development, advocacy, and research. So far, 12 tertiary and three secondary low vision clinics have been established and adequate personnel have been trained to run these and other centers. In addition four resource centers including text accessibility and eligibility centers have been supported in different parts of the country. These services are catering to the need of over ten thousand clients annually. The program has been running for the last 8 years and there has been an incremental increase in its coverage both in terms of clients accessing services and the geographical coverage. The program has also helped establish the need for optometric services in all public hospitals and there is a growing realization that comprehensive eye care cannot be offered without including optometrists. The program has witnessed a gradual transition from simple service delivery to more complex issues involving advocacy for disability issues and strengthening the opportunities for people to achieve their health rights.

Establishment of Low Vision Resource Centre (LVRC), Hong Kong.

One of the main constraints in provision of low vision services is the high cost and limited availability of low vision devices. To address this issue, LVRC has been established at the Hong Kong Society for the Blind under the auspices of Vision2020. This center procures high quality affordable devices and assessment tests from various sources and supplies these to programs across the world. Since its inception in 2003, over 120,000 low vision devices and assessment tests have been shipped to over 76 countries to programs in public and non-profit sectors. There has been dramatic reduction in the cost of devices. For example, an aspheric stand magnifier costs U.S. $3 and a 6X Keplerian telescope costs U.S. $13. Research has been conducted to help develop affordable low vision devices and vision assessment materials, which are now being used globally. Research work on the development of a new system for assessment of vision in infants is more challenging but has been initiated and field-testing of a second prototype is in process.

CONCLUSION

The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the world's main development challenges. The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations and signed by 147 heads of state and governments during the UN Millennium Summit in September 2000.¹¹

Goal 1: Eradicate extreme poverty and hunger.

Goal 2: Achieve universal primary education.

Goal 3: Promote gender equality and empower women.

Goal 4: Reduce child mortality.

Goal 5: Improve maternal health.

Goal 6: Combat HIV/AIDS, malaria, and other diseases.

Goal 7: Ensure environmental sustainability.

Goal 8: Develop a Global Partnership for Development.

Seven of the eight Millennium Development Goals cannot be achieved without taking appropriate measures to give all people in the world eye and vision help, particularly the millions of persons with blindness and visual impairment whose numbers include the majority of those who are unnecessarily blind due to uncorrected refractive errors. To address this issue in a meaningful way, it is absolutely critical to create a focus on development of human resources and models of service delivery that have the capacity to deal with this unnecessary burden of avoidable blindness. Over 650 delegates representing eye care professionals, researchers, governments, civil society, and industry from all over the world gathered at the Durban International Convention Center from March 14 to 16, 2007 to attend the first World Congress on Refractive Error and Service Development. The congress addressed the key public health challenge of uncorrected refractive error (the need for an eye examination and a pair of glasses), the leading cause of avoidable blindness and vision impairment across the world. A declaration addressing the key challenges was formulated (Durban Declaration),⁷ signed by all delegates, calls upon the Governments, International Organizations, and Professional Bodies to focus on and address the challenges of uncorrected refractive errors and take proactive steps to provide the solutions.

I would like to acknowledge the generous support we have received from our colleagues in the American Academy of Optometry who have always offered their whole-hearted support towards many of these initiatives.

Hasan Minto

Sightsavers International

United Kingdom