The estimated prevalence of blindness in 1990 ranged from 0.08% of children to 4.4% of persons aged over 60 years, with an overall global prevalence of 0.7%. Of the estimated 45 million cases of blindness by 1996, approximately 60% were due to either cataract (16 million people) or refractive errors. A further 15% were due to trachoma, vitamin A deficiency or onchocerciasis, with another 15% due to diabetic retinopathy or glaucoma. The remaining 10% of cases were attributable to age-related macular degeneration and other diseases. In view of the proportion of treatable eye diseases or treatable causes of blindness, such as cataract, trachoma, onchocerciasis and some eye conditions in children, it was estimated that 75% of all blindness in the world could have been avoided. (VISION – 2020 Global Initiative for the Elimination of Avoidable Blindness Action Plan 2006 – 2011, 2007) (Blindness in the Elderly, Editorial, 2008)
The risk factors for loss of vision are age, gender, poverty, and poor access to health care. It is estimated that more than 82.2% of all blind individuals are 50 or older. The burden for visual impairment accounts for approximately 3% of the total global burden of disease and 9% of total years lived with disability in 2001 (Loss of Vision and Hearing, Disease Control Priorities in Developing Countries, Second Edition, 2006). A comprehensive national assessment of the economic cost of visual impairment conducted in Australia, with five principal eye conditions – cataract, age-related macular degeneration, glaucoma, diabetic retinopathy and refractive error accounted for about 75% of all visual impairment (VISION – 2020 Global Initiative for the Elimination of Avoidable Blindness Action Plan 2006 – 2011, 2007). Multiple community based screening (Quigley, Park, Tracey, & Pollack, 2002), eye injury prevention (Luque, et al., 2007), and community based provisioning (American Optometric Association Community Health Centre Committee, Michelle Proser, Peter Shin, 2008) (Vision Centres, 2010) experiences guide towards adopting a comprehensive outlook catering to community ophthalmic needs.
The ICTPH Health Systems (Johar, 2010) strategy aims to facilitate a comprehensive healthcare delivery model for remote rural Indian population. With a unique community based health worker – ICTPH Guide provisioning screening and preventive healthcare services and a village based nurse-managed Rural Micro Health Centre (RMHC) provides a unique opportunity to explore a multi-dimensional approach. With individual health at the crux, establishing various preventive, diagnostic and curative interventions aims to achieve better health outcomes. This paper attempts to outline ICTPH’s strategy to integrate primary ophthalmic healthcare services in its unique healthcare delivery model.
Provisioning ophthalmic services at primary-care entails refractive error correction (myopia, hypermetropia, astigmatism, and presbyopia), cataract – detection, management and referral for surgical intervention, and managing chronic disease complications such as diabetic retinopathy and glaucoma through intraocular pressure assessment using tonometry and regular fundus examination using ophthalmoscopy.
The current infrastructure of a village-based Rural Micro Health Centre allows for suitable infrastructure advancement, facilitating ophthalmic capability, servicing a population of 10,000 people. To service the ophthalmic examination protocol, primarily a trial lens set + trial frame, a streak retinoscope and an ophthalmoscope are essential. For a higher order fundus examination a slit-eye lamp may be appropriate, but the substantial cost implication requires a careful community need assessment.
The nurse-managed Rural Micro Health Centres (RMHC) allows for multi-tasking/skill building a nurse to provision multiple diagnostic capabilities (Johar, 2010) at the village level inclusive of primary-level ophthalmic interventions. Given refractive error shares the largest disease burden, dispensing corrective prescription glasses may be essential. Through the RMHC network, a careful skill building exercise will allow servicing ophthalmic requirement of the local population, along with optimising task allocation across the RMHC network (e.g. combined corrective prescription glass dispensing facility across a network of five RMHCs servicing a population of 50,000 people).