Community Ophthalmology: Revisited

Visual impairment has immediate and long-term consequences in people of all age groups resulting in lost blind-person years, low educational and employment opportunities, poor economic gain for individual, families and societies and decreased quality of life.

Over the last 20 years, causes of blindness has changed both in proportion and actual numbers; however, cataract has still remained the major cause of blindness globally and more so in Asia. Globally (2) Available Indian estimates suggest that there are more than 12 million bilaterally blind persons in the country with visual acuity [VA] <6/60 in the better eye, of which nearly 7 million are with VA <3/60 in the better eye. National survey during 2001-04 indicated that prevalence of blindness stood at 1 Over the last few decades, multiple interjections of global advancement of knowledge, sharing of best practices and transfer of low cost technology, better classification of visually impaired, strong advocacy for fundamental right of blind persons and inclusive society has resulted in establishment of a distinct entity of 'Low Vision' amongst visually impaired. The person suffering from Low Vision are characterized by impairment of visual functioning even after medical, surgical treatment and/ or 'standard' spectacles; however, such person have potential to use vision for planning and/or execution of a task. The causes of low vision in older people vary. In general, it could be due to glaucoma, diabetes, macular degeneration, hypertensive retinopathy or retinal detachment. (3) People with 'Low Vision' are, in principle, capable of using their vision if given appropriate Low Vision Services including stimulating environmental/modification, assistive devices [e.g. Low Vision Devices (LVD) -high plus spectacles, magnifiers, telescopes, video-magnifiers, absorptive lenses, field expanding devices etc.], training, counseling and support; they do not necessarily need to use white canes or learn Braille. National Program for Control of Blindness has taken an initiative of increasing demand for low vision services through awareness generation activities, training of eye care teams on Low Vision, provision of selected LVD through identified Regional Institute of Ophthalmology [RIO], medical colleges and NGO institutions free of cost to BPL population.

Social Mobilization
Worldwide people are living longer and birth rates are declining. From public health perspective, blindness usually affects early and later age spectrum of life and both 'age cohorts' are dependent on 'others' for taking them to health system in their problem amelioration. Childhood blindness remains a significant problem due to cumulative loss of blind-person years in young children though its magnitude is relatively small when compared to extent of blindness in older adults, as 82% of all blind persons are 50 years and above. Female/male prevalence ratio indicate that women are more likely to have visual impairment than men in every region of the world even after adjustment for age; the ratio range from 1.5 to 2.20. (4) Outreach screening, transportation and accompanying escort becomes an essential strategy and a challenge for reaching out to such diverse, disperse and dependent population. The fundamental issue under any program is social mobilization for advancement of health objectives and increasing demand and utilization of services. It is expected that health personnel including community link worker like ASHA, Anganwadi workers and 'motivated' members of civil society and PRI can play a critical role in this aspect. Village-wise blind register is a tool that facilitates in identification, recording, communication, referral and appropriate management of such cases. Funds are dispersed for purchasing 'registers' but due to various human factors these are neither maintained nor updated for action in most of the places. There are many developmental nonophthalmic NGOs working in and with community that may not be currently associated with NPCB; a strategy to involve them at grassroot level is being devised for advancement of program objectives.

Community Ophthalmology
Curative ophthalmology can make a perceptible impact in the society only in conjunction with community ophthalmology. Such activities include need assessment, planning, mobilizing level appropriate resources, fact finding surveys, outbreak investigation in ophthalmic practices, targeted interventions through screening camps in collaboration with department of Ophthalmology, operational research, clinical care, Vitamin-A supplement/rich food, complete vaccination [especially measles], training, ophthalmic surveillance; sensitization, counseling, motivation, ensuring compliance, referral, follow-up, rehabilitation of incurable blind, empowering community/individuals to utilize available government concessions/benefit for the welfare of blind; reducing myths and misconceptions, understanding and removing barriers for access to services, facilitating favorable environment for growth and development; local leadership and coordination amongst stakeholders under various governmental departments of health, social welfare, education, PRI and ICDS, establishment of intra and inter-linkages, information, education and communication activities [IEC], promotion of eye donation, improving efficient client movement and logical disposal within health facilities, feedback/reminders for action, monitoring, supervision and evaluation.

Role and Contribution of Department of Community Medicine/PSM
Department of Community Medicine/PSM are undertaking/can uptake all the above activities in their area of jurisdiction and can strive to make it free from all causes of avoidable blindness. Since the scope and dimensions of the program has increased substantially in the Eleventh Plan, there is a huge potential and opportunity for department to participate and contribute. In an era of global recession where mantra of 'multi-tasking' has become a necessity rather than luxury, residents in the department of Community Medicine/PSM, in addition, can learn and enhance their ophthalmic screening and diagnostic skills. Howsoever small contribution it will be, still it will hold potential to benefit program at grassroot level.

Sentinel Surveillance Units
Sentinel Surveillance Units [SSU] conceptualized under NPCB have been established under department of Community Medicine/PSM in collaboration with the Department of Ophthalmology in selective 25 medical colleges. These units are frontline soldiers of the program in carrying out surveillance activities. Financial assistance to SSU has been enhanced from INR 1.5 lakhs to the tune of INR 3 lakhs from this year onwards so as to re-vitalize and rejuvenate them. However, some of the challenges and concerns in these units are lack of local leadership, inadequate coordination between departments, poor communication, incomplete/under reporting and a few pro-active community interventions. Nevertheless, NPCB is marching ahead steadily, consolidating gains, expanding in underserved/difficult to reach areas, year after year with involvement of stakeholders at all level. Meaningful results have already started appearing and long-term and sustainable impact will be evident in times to come.