Provisioning Ophthalmic Care for Remote Rural Indian Populations

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).

(Download the complete article here)

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7 Comments on "Provisioning Ophthalmic Care for Remote Rural Indian Populations"

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Nachiket Mor
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6 years 10 months ago

This is an excellent note Zeena. Well structured and comprehensive. I am not entirely convinced though about the propostion that population level screening is not required in rural areas for all those above 40 who are not wearing glasses — particularly for refractive errors. I personally felt that there would be a lot to be gained by screening every individual for refractive errors at the age of 45 and 50 — just two age points. Would be keen to hear your thoughts.

Zeena Johar
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Zeena Johar
6 years 10 months ago
Thanks Nachiket. As per my understanding screening aims to achieve improved disease outcomes by intervening to reduce individual risk of the disease or detecting the disease earlier on average than is usually the case in the absence of screening. Presbyopia clearly lists age as the prime risk factor, not sure if other refractive errors also demonstrate such age dependence. For cataract, population screening and early detection will add limited value, as a surgical intervention can be facilitated only at an advanced stage, and a clear symptomatic reporting e.g. blurring/loss of vision in the affected eye is seen. Diabetic retinopathy is… Read more »
Thulsi
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6 years 10 months ago
Zena, it is a good compilation to provide the essential understanding of the eye care and the common problems, solutions, etc. Would it be OK for us to use it in some of our own courses? From reading this blog and the longer document could not get a good sense of the details of eye care services and what exactly will be done. I guess this will evolve. However I understand that at 10,000 population (RHMC) level you will provide screening and referral services. Will it include some level of refraction? You propose to have spectacle dispensing for a cluster… Read more »
Zeena Johar
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Zeena Johar
6 years 10 months ago
Thulasiraj Sir thanks a lot for your kind words of appreciation. I will be delighted if my note will be of use for your curriculum. The essential services that we aim to provision through our RMHC are refraction (refractive error – diagnosis, assessment and dispensing of corrective glasses), and cataract management (diagnosis, referral and post operative care). To begin with, we will hire an optometrist for provisioning ophthalmic services to our populations, later transferring capability to the resident nurse at our RMHC. The proposed multi-tasking by a resident nurse needs careful evaluation, given the complexity associated with delivering ophthalmic care.… Read more »
Prajna
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6 years 10 months ago

Dear Sir,
This is a nicely prepared document, especially the intros . I am still not clear. From the discussion what we had, we suggested that all the centres will not be ophthalmology equipped? The document suggests that only the lens dispensing will be central. Considering the completeness of the examination protocols in this document, it would still be wise to set one centre exclusive for ophthalmology.
Prajna

K. Anitha
Guest
6 years 10 months ago

Ma’am, I read your blog post on ophthalmic care. We at the Karambayam RMHC have examined patients requiring a cataract surgery and refractive error correction. We feel that a screening program will be valuable.

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