EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/422211
EW INTERNATIONAL 56 December 2014 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," Dr. Prajna said. "In addition, there are very specific interventions that helped India to achieve this." These "interventions" include a "vibrant community" focused on eyecare 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 bring- ing down the cost of instruments, reimbursed NGOs for free surgeries, and paid for the training of govern- ment 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," Dr. Prajna said. A similar partnership has influ- enced the prevalence of blindness in China, where Dr. Li said that the government has invested significant- ly in medical insurance, blindness prevention networking, and decreas- ing the cost of the elimination of blindness. "We have a lot of programs on cataract blindness … including pro- grams 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 coop- erating with institutions such as his hospital, the Tianjin Medical University Eye Hospital. Economic development certain- ly plays a role. "With the declining poverty levels, most patients can now afford surgery," said Dr. Li. However, he added, this develop- ment 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 eyecare systems in the hope of creating a better balance between rural and urban levels of care. The "Sight First, China Action" project, in particular, "finished 2.93 million cataract surgeries, sent medical teams, trained doctors, established hospitals and training centers, and donated equipment," said Dr. Li. "Establishment of accessible, low-cost eyecare service centers that can adequately channel patients into an affordable eyecare service delivery model will be the key," Dr. Prajna said. "This model also uses the time of the ophthalmologists more efficiently. One ophthalmolo- gist in a tertiary center can effective- ly 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. In China, even as Dr. Li and his colleagues escalate their efforts to eradicate blindness from cataract and corneal disease, the significance of other causes such as uncorrect- ed refractive error, glaucoma, and age-related macular degeneration (AMD) and diabetic retinopathy is on the rise. Similarly, "India suffers from a 'cataract centric' focus on blind- ness prevention," said Dr. Prajna. "While this has been successful in the past, the future thrust should be on encompassing other age-related disorders such as AMD, diabetic retinopathy, etc." With existing cataract programs, "The low-hanging fruits have been plucked, but the approach should become even more comprehensive as we go along," he said. "As the disease burden goes from cataract to conditions such as glaucoma, diabetic retinopathy, etc., patients require continued care to offset the risk of blindness due to these disorders," he added. "While one-time surgical interventions effectively took care of reducing cat- aract blindness, the newer problems require surveillance and different treatment options based on indi- vidual response. At our institution at the Aravind Eye Care System, we have established 50 vision care cen- ters, each of which caters to a popu- lation of around 75,000 people." The key, he said, will be acces- sibility, more than affordability: "People are not going to travel far because they have been used to getting services at their doorstep. Internet penetration and mobile phone technology has permeated to the rural households, and hence ef- fective use of these media to educate patients to access a primary vision care center should be the goal." Broadly speaking, the strategy in this case, according to Dr. Li, would shift from intervention in the form of surgery to education and prevention. "Moving to the new blindness causes like AMD and especially dia- betic retinopathy, I think it's better to promote or enhance people's awareness," he said. In China, in addition to surgical missions and developing local resources, "we also have a lot of public forums and write articles in newspapers to educate people on diabetes and AMD," he added. Ongoing struggle The Lancet study highlights the posi- tive experiences of ophthalmologists working in countries like China and India, whose efforts through the years have made a significant impact on a truly life-altering condition. It should also be noted, however, that the study's analysis combined with the experiences of doctors in the re- gion demonstrates that the situation is not lacking in complexity, and the struggle gathers nuance as im- proving healthcare and healthcare delivery increase longevity and pop- ulations continue to age around the world. Programs aiming to eradicate blindness will thus need to adapt to continue making progress. In any case, ophthalmologists such as Drs. Li and Prajna remain committed to the struggle, and con- tinue to work on the eradication of all preventable and treatable causes of blindness around the world. EW Reference 1. Bourne RRA, Stevens GA, White RA, et al. Causes of vision loss worldwide, 1990–2010: A systemic analysis. The Lancet Global Health. Dec 2013;1(6):e339–e349. Editors' note: Drs. Li and Prajna have no financial interests related to this article. Contact information Li: xiaorli@163.com Prajna: prajna@aravind.org Blindness decreases continued from page 54 "India suffers from a 'cataract centric' focus on blindness prevention. While this has been successful in the past, the future thrust should be on encompassing other age-related disorders such as AMD, diabetic retinopathy, etc." –N. Venkatesh Prajna, DNB, FRCO