▪Public health ophthalmology / Preventive eye care/ Community ophthalmology ▪To provide an ophthalmologic service; identifying and preventing eye sight threatening ocular condition, to whoever (mass, large number) in community

1. PREVENTIVE AND COMMUNITY
OPTHALAMOLOGY
Presented and prerviewed by
Miss.DIVYA PATIL

2. Preventive Ophthalmology
▪Public health ophthalmology / Preventive
eye care/ Community ophthalmology
▪To provide an ophthalmologic service;
identifying and preventing eye sight
threatening ocular condition, to whoever
(mass, large number) in community

3. Clinical application
General method of preventive
healthcare

4. Primary prevention
▪To prevent people from disease.
▪Eliminate or limit the risk factors and pathogen exposure.
Methods
Community immunization
Environmental control
Health care system management :

5. Secondary prevention
▪To prevent disease’s progression and disability
▪Early diagnosis
Screening may not efficient and value in every diseases.
We consider to do in case of…
High severity
High incidence and prevalence
High understanding of pathogenesis
There’re effective treatments available
Screening tool is accurate, accountable and affordable

6. Secondary prevention
Worth screening diseases
▪Cataract
▪Diabetic retinopathy
▪Amblyopia
▪Glaucoma

7. Tertiary prevention
▪To rehabilitation, correction of disability
Examples :
Blindness rehabilitation
Keratoplasty

8. Child with low risk
▪Ocular examination should be done once the infant born, 6
months , 3 years and at 5-6 years
Once they born : external eye examination, ocular alignment
(Hirschberg’s test), ophthalmoscopy
6 months :VA, Ext eye examination, pupillary exam, ocular
alignment, ophthalmoscope (Red reflex)
3 years:VA (Picture,Egame), Ext eye examination, pupillary exam,
ocular motility and alignment, ophthalmoscope (Red reflex)
5-6 years :VA (Snellen), Ext eye examination, pupillary exam,
ocular motility and alignment, ophthalmoscope (Red reflex and
fundus)

9. Child with high risk
▪Refer to ophthalmologist
▪Defining high risk…
Preterm
Family history of cataract,
retinoblastoma, strabismus
or amblyopia
*Systemic disease

10. Adult with low risk
•6-40 year-olds :VA q 3 year
•> 40 year-olds : refer to ophthalmologist q 2-4
year for presbyopia and glaucoma screening
Adult with high risk
▪Refer to ophthalmologist q 1-2 years
▪Defining high risk…
Hxof Retinal detachment/Severe ocular
trauma
Low vision
Underlying disease : DM, HT
Family Hxof Glaucoma, eye disease
Over 65 year-olds

11. Amblyopia & Strabismus
▪Primary prevention
–Screening for causes of from deprivation within the first 4-6 weeks
after birth, and children at risk should be monitored yearly to 4 years of
age
Newborn to 3 months of age
–Red reflex test with a direct ophthalmoscope.
–External inspection of the eyes to assess for any structural
abnormalities (penlight exam is sufficient).
–Pupillary exam.

12. Amblyopia & Strabismus
3-6 months of age
–Tests for newborn to 3 months are repeated.
–Tests to check whether the infant can fix and follow with each eye
independently.
6-12 months of age, and then yearly until the child
can co-operate with verbal visual acuity testing
–Tests for newborn to 3 months are repeated.
–Corneal light reflex test, to check for a symmetrical response in
both eyes.
–Alternate occlusion of each eye: the infant's behavioral response
should be equal to having either eye occluded. In other words, the
infant should object or not object equally.

13. Amblyopia & Strabismus
3-4 years of age
–Tests for newborn to 3 months are repeated.
–Corneal light reflex test, to check for a
symmetrical response in both eyes.
–Cover/uncover test to assess for re-fixation
movements.
–Visual acuity testing, independently for each eye.
Visual acuity of 20/50 or worse, or a ≥2 line
difference between the 2 eyes, should be referred.

14. Amblyopia & Strabismus
5 years of age
–Tests for newborn to 3 months are repeated.
–Corneal light reflex test, to check for a symmetrical
response in both eyes.
–Cover/uncover test to assess for re-fixation movements.
–Visual acuity testing, independently for each eye.Visual
acuity of 20/40 or worse, or a ≥2 line difference between the
2 eyes, should be referred.

15. Amblyopia & Strabismus
▪Secondary prevention
The American Academy of Ophthalmology recommends that
patients who are functionally monocular due to amblyopia
should help to prevent vision loss to the better-seeing eye by
–Wearing polycarbonate spectacles even if they do not
require refractive correction
–Wearing protective goggles and facial protectionfor contact
sports and potentially dangerous activities such as paintball
–Having regular eye examinations throughout life.
Reference: Bestpractice(BMJ group): Amblyopia

16. Amblyopia & Strabismus
▪Tertiary prevention
–Follow up at 2, 4, 6, 8 and 12 months are
recommended

17. Congenital cataract
▪A congenitalcataractis a clouding of the lens of the eye
that is present at birth.
Risk factors
–Genetic disease, birth defect
–Intrauterine infections : maternal rubella
22

18. Congenital cataract
▪Primary prevention
–Genetic counseling
–Measles, rubella vaccine
▪Secondary prevention
–Early detection: leukocoria
–Surgery
23

19. Occupational ocular injuries
▪Radiation Burns UV radiation burns (welder’s flash)
routinely damage workers’ eyes and surrounding tissue,
leading to epithelial keratitis

20. Visual impairment in
adult
Refractive error
▪Refractive error
–Myopia, Hyperopia,Astigmatism
–Risk factor
▪Family history
▪Previous history of ocular trauma, surgery,
infection
▪Near-work
▪Primary prevention
–Avoid risk factor
▪Secondary prevention
–Optical correction
▪Spectacle
▪Lens
▪Refractive surgery
▪Tertiary prevention
–Prevent amblyopia by Optical correction
Glaucoma
▪Risk factor
–Age>40 years
–Asian
–Family history
–Refractive error
–Steroid
▪Primary prevention
–Avoid Risk factor

21. Blindness and low vision
Blindness
▪Definition
–The inability to see
▪TheWorld Health Organization (WHO)
–best corrected visual acuity of 3/60 or less, in the better eye
Vision
▪The sense by which objects in the external environment are
perceived by means of the light they give off or reflect.
▪The act of seeing.

22. Low vision
▪TheWorld Health Organization
(WHO)
Visual acuity less than 6/18 and equal
to or better than 3/60 (10/200) in the
better eye with best correction

23. Global Prevalence ofVisual
Impairment
▪Vision 285million people are estimated to be visually
impaired worldwide: 39million are blind and246 have low
vision.
▪About 90% of the world's visually impaired live in
developing countries.
▪82% of people living with blindness are aged 50 and above.
▪Globally, uncorrected refractive errors are the main cause
of visual impairment; cataracts remain the leading cause of
blindness in middle-and low-income countries.
▪The number of people visually impaired from infectious
diseases has greatly reduced in the last 20 years.
▪80% of all visual impairment can be avoided or cured

24. Number of people (in thousands) blind, with low vision and visually impaired per million
population

25. COMMUNITY
OPHTHALMOLOGY

26. 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

27. These solutions comprise of –
a. Preventive activities for control of communicable and
noncommunicable
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.

28. 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 asWORKVISION
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.

29. 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 asWALKVISION.
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.

30. 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%

31. VISION 2020:THE RIGHTTO SIGHT
- Global initiative launched by the World Health
Organization and
aTask 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 theWorld Health Organization, Dr. Gro
Harlem Brundtland.

32. - 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 ofVision 2020
They are-.
- Cataract
-Trachoma
- Onchocerciasis
- Childhood blindness
- Refractive Errors and LowVision

33. 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

34. 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

35. 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.

36. 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.

37. - 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.

38. 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

39. 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 inYemen.
Aim
Elimination of blindness due to onchocerciasis.

40. 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.

41. Refractive Errors and LowVision
- 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

42. 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

43. 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.

44. 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

45. 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)

46. 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.

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

48. THANK YOU