Primary Health Care Eye Health Sensitization This presentation

Primary Health Care Eye Health Sensitization This presentation was developed by The Caribbean Council for the Blind with financial support for the European Union

Aim of PHC training • To sensitize (at least) 1, 240 Primary Healthcare/community workers and teachers. • To promote eye health awareness and screening of children and adults at the community level • To develop the ability to identify and refer cases to secondary facilities. • To sensitize a network of individuals with the common goal of screening up to 6 million people over the next 5 years. • To contribute to the reduction of the prevalence of blindness and visual impairment in the targeted countries (including) Guyana, Haiti, Jamaica and St. Lucia.

What is Vision? What is Vision Acuity? What is Functional Vision?

Visual Acuity describes the degree of visual resolution Contrast is the ratio of light/dark and describes the border of the image ( reduced contrast is often describes as ‘glare’)

Vision Acuity (in the better eye with presenting vision) VA Min of Arc 20/20 20/40 20/60 1 min 2 min 3 min 20/70 20/200 20/400 20/1000 3. 5 min 10 min 20 min 50 min WHO Definition Normal mild LV WHO definition LV Mod LV Severe LV Profound LV Near total blindness

Functional Vision • • Bangkok definition: A person with low vision is one who has impairment of visual functioning even after treatment and/or standard refractive correction and has a visual acuity of less than 6/18 to light perception, or a visual field less than 10 degrees from the point of fixation, but who uses, or is potentially able to use vision for the planning and/or execution of a task. (WHO, 1992) Levak (1991) Definition: Having a significant visual impairment but also having some usable vision: moderate low vision is acuity of 20/70 – 20/160 (better eye with correction) severe low vision is acuity of 20/200 – 20/400 or visual field of 20 degrees or less Corn (1981)Definition: One who is still severely visually impaired after correction, but who may increase visual functioning through the use of optical aids, non-optical aids, and or techniques

Premise • There are differences in the ways children with congenital low vision and adults with adventitious low vision use and learn to use vision • There are differences with how children and adults with different types of low vision (e. g. , low acuity, reduced visual fields) use and learn to use vision.

Premise • There are different levels of visual efficiency that can be achieved at different levels of visual functions (e. g. , 20/100 vs. 20/800). • Visual functions and functional vision go hand in hand.

Prevalence of Blindness How Big a Problem is It

Global Picture • • 37 million blind 7 m with NLP = require substitute training Of 30 m remaining… 50% require surgery 15 m requiring low vision care • 124 million Low Vision • 74 m require cataract surgery (60%) • 50 m requiring low vision services • 15 + 50 = 65 m needing Low Vision Services 10

Caribbean Picture • Blind – Prevalence 1% of the population • Causes of blindness – – – Cataract: 52% Cataract and Open Angle Glaucoma: 9% Open Angle Glaucoma alone: 10% Diabetic retinopathy: 10% Others: 19% • Low vision – Prevalence 3% of the population

Anatomy Of The EYE

CORNEA clear, transparent section of the outer coat of the eyeball SCLERA white part of the eye forming an external protective coat CHOROID IRIS vascular, intermediate coat providing nourishment to the eyeball coloured part of the eye in front of the lens regulating the amount of light entering the eye by changing the size of the pupil opening at the centre of the iris PUPIL LENS RETINA MACULA transparent body that focuses light passing through the eye on the retina the innermost lining of he eye connected with the optic nerve and upon which any visual image is focused. Has ‘nerve’ cells for sight (rods and cones) small depression in the retina adapted for fine vision OPTIC NERVE part of the central nervous system carrying the sense of sight from AQUEOUS the retina to the brain. clear, watery fluid that fills the front part of the eye VITREOUS transparent, gelatinous material filling the eyeball behind the lens

Priority Eye Conditions in the Caribbean • • • Cataract Diabetic Retinopathy Glaucoma Childhood Blindness Uncorrected Refractive Errors and Low Vision

Cataract • Cataract is clouding of the lens of the eye which impedes the passage of light. Although most cases of cataract are related to the ageing process, occasionally children can be born with the condition, or a cataract may develop after eye injuries, inflammation, and some other eye diseases.

Cataract

Prevalence of Cataract • Global – Age related cataract is responsible for 48% of world blindness, which represents about 18 million people. Caribbean (Barbados Eye Study) – Cataract is responsible for 52% of blindness

Prevalence of Cataract Cont’d • Although cataracts can be surgically removed, in many countries surgical services are inadequate, and cataract remains the leading cause of blindness. As people in the world live longer, the number of people with cataract is growing. Cataract is also an important cause of low vision in both developed and developing countries. Even where surgical services are available, low vision associated with cataract may still be prevalent, as a result of the long period spent waiting for operations and barriers to surgical uptake, such as cost, lack of information, and transportation problems.

Treatment of Cataract • The treatment of cataract is an operation, which is very successful in restoring sight. The opaque lens is removed and replaced by an artificial intraocular lens.

Before After This workshop is funded by the European Union

Risk Factors for Cataract • • Age diabetes mellitus hypertension trauma high body mass cigarette smoking ultraviolet light exposure alcohol consumption

Diabetic Retinopathy • • Definition Prevalence Treatment Risk Factors

Definition of DR • Characteristic group of lesions found in the retina of individuals having had diabetes mellitus for several years. Diabetic retinopathy is considered to be the result of vascular changes in the retinal circulation. • In the early stages vascular occlusion and dilations occur. • Progresses into a proliferative retinopathy with the growth of new blood vessels • Macular edema (the thickening of the central part of the retina) can significantly decrease visual acuity.

Prevalence of DR • It is estimated that in 2002 Diabetic Retinopathy (DR) accounted for about 5% of world blindness, representing almost 5 million persons who are blind. • In the Caribbean DR has a prevalence of 5. 9% and increases to 28. 5% for those who suffer from Diabetes. (Barbados Eye Study) • As the incidence of diabetes gradually increases, there is the possibility that more individuals will become blind from the disease

Treatment of DR • The following actions can decrease some of the risk to vision caused by diabetic retinopathy. • Eating a balanced diet and reduced consumption of sugar sweetened drinks. • Regular exercise, including walking as much as possible. • Maintaining a normal blood sugar level.

Risk Factors for DR • • Duration of diabetes Level of glycemia Presence of high blood pressure Dependence on insulin Pregnancy Levels of selected serum lipids Nutritional and genetic factors

Glaucoma • Increased Intra-Ocular Pressure (IOP) • Changes in Optic Nerve • Peripheral Vision

Diagnosis for Glaucoma • A precise comprehensive definition and diagnostic criteria are yet to be finalised. People with glaucoma probably lose their sight because increased pressure in the eye and other factors (such as poor blood flow) affect the optic nerve at the back of the eye. The eye slowly loses nerve function, and loss of side (peripheral) vision. This occurs painlessly, even unnoticeably. • There are several types of glaucoma, however, the two most common are primary open angle glaucoma (POAG), having a slow and insidious onset, and angle closure glaucoma (ACG), which is less common and tends to be more acute.

Prevalence of Glaucoma • Worldwide – 61 million projected – 8 million by 2020 • US – 1. 86% > age 40 – 10% > age 70 • Caribbean (Barbados Eye Study) – 7% > age 40 – 16% > age 70

Treatment of Glaucoma Open-Angle Glaucoma • Treatment with eye drops to decrease the IOP. Note: you may need to change from one type to another. This is a life-long disease and your eyes must be checked regularly to make sure you are getting the best treatment. You must follow the strict medication schedule your doctor gives you. You must not allow your glaucoma drops to run out • Surgery is an option (trabeculectomy) • Glaucoma patients should be encouraged to request this option. • Will Help to prevent further loss of vision.

Risk Factors for Glaucoma • • Family History Age Nearsightedness Ethnic background Raised IOP Trauma Diabetes Cataract

Childhood Blindness • • Definition Prevalence Treatment Risk Factors

Definition of Childhood Blindness • Childhood blindness has many causes. In poor countries the main ones are: – corneal scarring and cataract. – ROP (Retinopathy of prematurity) – Some causes of blindness is hereditary.

Prevalence of Childhood Blindness • 1. 4 million are children under 16. (of the 45 million global blindness) • 1. 5 per 1000 In low-income countries • 0. 3 per 1000 children in high-income countries • Closer to 1 per thousand in Caribbean countries. • The vast majority of childhood blindness happens before the age of five. • Puberty is believed to be a significant cause of visual impairment –Usually correctable with prescription glasses.

Treatment • Prevention and treatment of childhood blindness is disease specific. • Properly planned and implemented national vaccination programmes against measles has reduced the prevalence of eye complications. • In middle income countries, retinopathy of prematurity (ROP) is among the leading causes of blindness, the incidence of which can be reduced through availability and affordability of screening and curative services. • Early treatment of cataract and glaucoma can be beneficial, while low vision devices are helpful in children with residual vision. • Early detection of visual impairment and prescription of appropriate eye glasses, is important.

Uncorrected Refractive Errors and Low Vision • • Definition Prevalence Treatment Risk Factors

Definition of Refractive Error • myopia (short-sightedness) • hyperopia (long-sightedness) • astigmatism (when the eye can sharply image a straight line lying only in one meridian).

Prevalence of Refractive Error • World wide, severe refractive errors have been estimated to account for about 5 million persons who are blind. • According to the most recent data available to WHO, there an estimated 124 million people in the world with low vision. • Caribbean Prevalence – Myopia 22% >age 40 – Hyperopia 47% > age 40

Treatment of Refractive Error • Refractive errors can be rectified with appropriate optical correction GLASSES

Presbyopia • As people age, they often begin to have difficulty focusing their eyes for reading or close work. This is called presbyopia and is the normal aging of the eyes. It usually affects people over the age of forty as the eye starts to lose some of its flexibility. • Treatment This condition is easily corrected with eye glasses of increasing strength as a person ages. Bifocal of trifocal lenses may be prescribed to some people with presbyopia who also have other refractive problems such as myopia (near-sightedness), hyperopia (far-sightedness) or astigmatism (distorted vision due to a irregularly shaped cornea).

Definition of Low Vision • (WHO) Low vision is visual acuity less than 6/18 and equal to or better than 3/60 in the better eye with best correction. When does a person require Low Vision Services ? • One who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception, or a visual field less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of a task for which vision is essential.

Prevalence of Low Vision • There an estimated 180 thousand persons in the Caribbean with low vision. • Three (3) out of every one hundred persons in your village-district could be affected by low vision. • 1 out of every 4 could benefit from low vision services

Treatment of Low Vision • • Lighting Environment Magnification Vision Aids

Environment • • • Lighting Improved Contrast Bold Magnification Tactile

Vision Aids • People with low vision may be helped with low vision device – Magnifiers – Telescopes – CCTV – JAWS

Magnifiers This workshop is funded by the European Union

Magnifiers This workshop is funded by the European Union

Telescope This workshop is funded by the European Union

Vision Assessment • • • History Distance Acuity Near Vision Other Referral Follow Up

Vision Assessment Tools This workshop is funded by the European Union

Eye Screening • Correct Environment – lighting – noise – distractions • Correct Distance – 20 foot – 10 foot • Correct Tool – choice of chart

This workshop is funded by the European Union 11/29/2020 57

This workshop is funded by the European Union 11/29/2020 58

School Eye Screening WHO? • Kindergarten • Grade 6

School Eye Screening

Community Health Fairs This workshop is funded by the European Union

Referral Process • What Perimeters for Referral? • Who to Refer to? • Follow-Up?

Referral Form • This is a sample referral form used by St. Lucia Blind Welfare Association • Each country should use their own referral form or referral system

PRESENTED BY Tel: (268) 462 -4111/462 -6369 E-MAIL: info@eyecaribbean. com www. eyecaribbean. com The End