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Optometry as part of Vision 2020: global perspective. Kovin Naidoo ICEE Africa Director AFCO Vice-President. World Health Organisation- IAPB. Global Initiative to Eliminate Avoidable Blindness by the Year 2020. < 6/18 - 3/60 <0.3 - 0.05. < 3/60 <0.05. Low Vision. Blind.

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Kovin Naidoo ICEE Africa Director AFCO Vice-President

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Optometry as part of Vision 2020: global perspective

Kovin Naidoo

ICEE Africa Director

AFCO Vice-President


World Health Organisation- IAPB

Global Initiative to Eliminate Avoidable Blindness by the Year 2020

present situation

< 6/18 - 3/60

<0.3 - 0.05

< 3/60





Present situation
  • Present estimation:
    • 45 million people blind


    • 135 million visually disabled

Best corrected VA

International classification ignores the burden of uncorrected refractive error

prevalence of blindness
Prevalence of Blindness

90%+ live in

underprivileged communities

The ‘blindness’ rate in many developing countries, especially in Africa, is 7 times higher, at 1.4%, than in developed countries
global distribution of blindness by cause
Global Distribution of Blindness by Cause


28 %

Macular degeneration

Diabetic retinopathy


Refractive errors



1 %




42 %


15 %

present situation9
Present situation

80% of blindness is avoidable




leading causes of preventable blindness
Leading Causes of Preventable Blindness:
  • Cataract
  • Trachoma
  • Onchoceriasis
  • Childhood Blindness
  • Refractive Error& Low Vision
vision 2020
  • Vision 2020 will strive to make refractive services and corrective spectacles affordable and available to the majority of the population through primary health care facilities, vision screening in schools and low-cost production of spectacles. Similar strategies will be adopted to provide low vision services.
global estimates
Global estimates
  • Magnitude of refractive errors not reliably known
  • Large global variation in prevalence (by age, gender, and race)
  • Estimated: 2.3 billion people have refractive error
    • 1.8 billion have access to refractive services
    • 500 million do not have access to services

Blindness Due To Uncorrected Refractive Errors (<3/60)

China 4.4% Due to RE:10%

Shaozhen Li, 1999 (n=5342)

India 2.5% Due to RE:9.6%

Dandona, 1998 (n=2522)

10%+ of WorldBlindness

Sth Africa 1.0% RE:10%

Cook, 1992 (n=268)

Australia 0.15% Due to RE:25%

Taylor, 1997 (n=3268)

Saudi Arabia0.7% RE: 5.3%

Al Faran, 1993 (n=2882)

difficulties with current data
Difficulties with Current Data
  • Non-uniform definitions across studies
  • Non-representative study populations (convenience rather than population-based)
  • Dissimilar demographics of study population (age and sex)
  • Refraction procedures are different (with/without cycloplegia etc)

Negrel, Ellwein, 2001

uncorrected refractive error is the major cause of
Uncorrected refractive error is the major cause of:

blindness following mass cataract surgery using standard power IOL

low vision
Low Vision
  • 35m people worldwide have irreversible vision loss and are in need of low vision care.


Low vision care & vision correction

  • VISION 2020will enable access to visual devices & low vision care at affordable cost

*WHO Global Initiative: Vision 2020, Feb 1999

  • Disease control through service delivery
  • Human resource development
  • Infrastructure and technology
  • has created valuable and effective collaborations of organisations
  • WCO until 2002 was not a part of the International Agency for the Prevention of Blindness
optometry a late entrant
Optometry a late entrant
  • It is only recently that uncorrected refractive error and even more recently low vision has achieved prominence
  • Landmark population-based studies in adults, children and in post-cataract patients.
optometry and public health
Optometry and Public Health
  • Mainly private practice
  • Limited discourse about public sector initiatives
  • Individual Optometrists and groupings efforts
public health challenges
Public Health Challenges
  • Integration of professions
  • Expansion of the scope of Optometry
  • Consolidation of the scope of Optometry
  • Charity vs Public Health
  • Health Policy
  • Health Systems development and Management
  • Health Promotion
opportunity for optometry
Opportunity for Optometry
  • The realisation of the impact of uncorrected refractive error and Low Vision has provided the opportunity for optometry to play a major part in alleviating vision loss for those most in need.
refractive error and vision 2020
Refractive Error and Vision 2020
  • WHO established a Refractive Error Working Group (REWG), as
  • The REWG is now developing international strategic plans and policies to eliminate uncorrected refractive error.
  • Children:
  • -Myopia: < 0.5D
  • -Hyperopia: 2D
refractive error in children
Refractive error in Children
  • -Binocular vision <6/12 is considered significant
  • -Should only occur when appropriate resources for follow-up refraction and delivery of spectacles.
  • -Visual acuity screening of children can be performed at community level by teachers, health care workers etc.
refractive exams
Refractive exams
  • Children:
  • Exams should be carried out only by eyecare personnel(ECP) with the appropriate skills in objective and subjective refraction, ocular motility, basic eye examination, ability to detect potenially blinding diseases and communication skills.
minimum standards for children
Minimum Standards for Children
  • -Retinoscopy plus subjective refraction, with cycloplegia for young children as needed.
  • -Autorefractometry plus subjective refraction with cycloplegia
refractive correction priority
Refractive Correction: Priority
  • -High Priority: < 6/18
  • -Moderate Priority: <6/12
  • -Low Priority: <6/9
  • -Children: < 6/12
  • -Adults: < 6/18
priority groups
Priority Groups
  • Children aged 11-15 with myopia and people over the age of 45 years who require spectacles for near vision
not restricted to refraction
Not Restricted to Refraction
  • Integrated into the eye team and blindness prevention
  • Teaching eye care personnel, especially in refraction and low vision care
  • Providing screening and vision care services at secondary and tertiary levels
  • Detection and management of potentially;blinding diseases such as cataract, diabetes and glaucoma
  • Research into the understanding of global eyecare needs and solutions,especially in vision correction and vision care service delivery
  • Building models of self-sustainable eyecare.
optometry s role in correcting refractive error
Optometry's Role in Correcting Refractive Error
  • Public health optometry has not reached the
  • communities that are in most need in any organised way.
  • Develop a concerted effort to create local capacity in these communities, in collaboration with its partners in Vision 2020, through service delivery, by creating human resources and by helping to develop the infrastructure needed, the three cornerstones of the Vision 2020 programme.
what is needed
What is Needed?
  • Developed countries: optometrist to population ratio is 1:10,000.
  • Developing countries the ratio is 1:600,000, and much worse in many rural areas, up to millions of people per optometrist.
what is needed34
What is needed?
  • Increase in the number of eyecare personnel trained in refraction and vision correction.
  • Training mid-level personnel in refractive care.
  • Interim measures using nurse-refractionists or ophthalmic or optometric technicians that refract are essential.


Vision 2020

Ophth., Opt., Managers


OphN., Oph.Tech, Dispensing Opt.

Mid Level Personnel

Com Worker, Teacher, PHCW

Comm. Level

One effective current model, developed by the LV Prasad Eye Institute in Hyderabad,
  • India, for the efficient and cost-effective delivery of eyecare is a community eyecare
  • ‘team’. For every 1,000,000 people the team has:
  • · 1 ophthalmologist
  • · 4 optometrists
  • · 8 eyecare workers
  • · 8 ophthalmic assistants
  • · 16 ophthalmic nurses.
what is needed38
What is needed?
  • Establishment of infrastructure
  • Development of effective models and
  • Programmes
  • Funding needed for the provision of training and low cost spectacles.
  • Low Cost laboratories
Refraction services as an integral part of general health care systems and
  • comprehensive eyecare.
the role of research
The Role of Research
  • Adequate prevalence data determines those most in need of intervention
  • Provide the basis from which interventions in the future can be evaluated
african vision research institute avri

African Vision Research Institute (AVRI) addresses

the need for Africa based eye research.

Based in South Africa it will link:

  • Intellectuals
  • Institutions
  • Organizations
  • Other personnel in the pursuit of solutions to the various community eye health issues in Africa.
Optometry can significantly contribute to the understanding of:

Worldwide blindness and impaired vision-the burden and its effects

Health care planning

Service delivery

Outcomes of intervention.

self sustainability refractive error and optometry
Self-Sustainability, Refractive Error and Optometry
  • Developing the logistics and economics of self-sustaining eyecare at the
  • community and institutional levels
  • · Mobilising worldwide resources to develop models and create the educational and delivery infrastructure for refractive and general vision care.
cross subsidization
Cross Subsidization
  • Spectacle supply can effectively fund more expensive or
  • Intensive needs such as low vision and cataract surgery.
  • Refract and supply spectacles and vision care, including the
  • Detection and treatment of minor problems, and referral of those with more serious problems, at the community level.
  • Optometry can make a major contribution in supporting eye care at this more convenient and cost-effective level.
optometry s response
  • Public Health and Development Committee of WCO
  • Vision 2020 membership
  • OGS
  • Public Health Agenda
  • Membership in Country of Vision 2020 committees
  • Involvement in the National Plan
tanzanian opportunties
Tanzanian Opportunties
  • Community Optometry a model for the world
Preventable blindness is one of our most tragic and wasteful global problems.
  • Optometry is an essential part of the team that will eliminate this tragedy, by understanding global eyecare needs and delivering effective and sustainable visioncare to people in need, thereby ensuring their fundamental right to sight.