EyeWorld Asia-Pacific June 2014 Issue

65 EWAP NEWS & OPINION June 2014 continued on page 66 Blindness decreases…in the Asia-Pacific by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer As worldwide blindness decreases, the problem also grows more complex, as revealed by the experience of experts in China and India T he last two decades have seen ophthalmologists from around the world become increasingly engaged in the eradication of preventable and treatable forms of blindness. Owing at least in part to these efforts, the 20-year span from 1990 to 2010 saw a 3% decrease—from 68% to 65%— in the number of people around the world blind from preventable and treatable causes, according to a study published in the December 2013 issue of The Lancet Global Health . This change may seem negligible, particularly in light of the actual numbers, remaining close to 32 million people throughout that time period. However, the study’s lead investigator, Rupert R.A. Bourne, MD, Vision and Eye Research Unit, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, UK, said that the world’s aging population masks the significance of the change. Over half of the world’s population lives in the Asia-Pacific; here, EyeWorld Asia- Pacific focuses on two of the world’s most populous countries—China and India—to see how the fight against blindness in the region has progressed over the same time period, whether the Lancet study’s findings reflect the experience in the region. Shifting causes In India, “the answer is a resounding ‘YES’,” said to N. Venkatesh Prajna, DNB, FRCO, Chief, Cornea Clinic, Aravind-Madurai, and Director, Academics, Aravind Eye Care System, India, in correspondence. “The incidence of blindness has reduced from 1.4% in 1976 to 1% in recent times (vision of less than 6/60).” Meanwhile, in China, the number of visually disabled people also decreased gradually over the years, said Li Xiaorong, MD, PhD, Director, Tianjin Medical University Eye Hospital, China, citing papers that put the current prevalence of blindness in China at 2.29%. This is particularly true in terms of cataract. Before, said Dr. Li, patients with cataract could not accept the cost of cataract surgery, especially in difficult cases involving white, mature cataracts. “With the development of the technique, some cataracts that could not be treated before now can be treated, so most of them can recover from blindness,” he said. Dr. Prajna’s experience is comparable. In India, he said, “the proportion of cataract as a cause of blindness has come down. Twenty years back, cataracts used to be responsible for 80% of blindness, while now it is estimated to be around 60%.” Despite these developments, cataract remains the leading cause of blindness in both countries. Nonetheless, the profile of preventable or treatable blindness is certainly changing, with the predominance of cataract now giving way to other conditions. In China, for instance, where blindness eradication programs have helped reduce blindness from cataract as well as corneal disease, the significance of other causes such as uncorrected refractive error, glaucoma, and, more particularly, age-related macular degeneration (AMD) and diabetic retinopathy is on the rise. Reaching out for balance The Lancet paper attributes the decrease in global blindness to a combination of factors including a decline in poverty levels, improved public health measures, and eye health service development. “The comments of Dr. Bourne are valid in the Indian context as well,” said Dr. Prajna. “In addition, there are very specific interventions which helped India to achieve this.” These “interventions” include a “vibrant community” focused on eye care led by non-government organizations (NGOs) and active support from the government. Specifically, the Indian government established district blindness control societies, removed import duties for ophthalmic equipment— thus bringing down the cost of instruments, reimbursed NGOs for free surgeries, and paid for the training of government doctors. “The success has been due to complementary roles played by the Government and the Non- Government Organizations in a unique example of public–private partnership,” said Dr. Prajna. A similar partnership has influenced the prevalence of blindness in China. “We have a lot of programs on cataract blindness…including programs for poorer cataract patients,” said Dr. Li. These programs, he said, involve organizations such as the China Disabled Person’s Federation and the All-China Federation of Returned Overseas Chinese cooperating with institutions such as his hospital, the Tianjin Medical University Eye Hospital. Economic development also plays a role, although in China, said Dr. Li, this development is “not so balanced”. “In the major cities, there’s no problem,” he said. Patients in city centers such as Beijing and Tianjin enjoy a high level of care not available to people living in China’s rural counties. Institutions such as the Tianjin Medical University Eye Hospital have thus established outreach programs that send doctors to rural counties not just to perform cataract surgery but also to develop local resources, training local doctors to create sustainable eye care systems in the hope of creating a better balance between rural and urban levels of care. “Establishment of accessible, low-cost eye care service centers which can adequately channel patients into an affordable eye care service delivery model will be the key,” said Dr. Prajna. “This model also uses the time of the ophthalmologists more efficiently. One ophthalmologist in a tertiary center can effectively manage 6-7 vision centers.” Beyond ‘low-hanging fruit’ Going forward, both Drs. Li and Prajna agree that the approach to blindness must begin addressing other causes. “India suffers from a ‘cataract centric’ focus on blindness prevention,” said Dr. Prajna. “While this has been successful in the past, the future thrust should be