PUBLIC HEALTH AND THE EYE

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1 SURVEY OF OPHTHALMOLOGY VOLUME 50 NUMBER 1 JANUARY FEBRUARY 2005 PUBLIC HEALTH AND THE EYE JOHANNA SEDDON AND DONALD FONG, EDITORS Present Status of Eye Care in India Ravi Thomas, MD, 1 Padma Paul, MS, 1 Gullapalli N Rao, MD, 1 Muliyil JP, MD, 2 and Annie Mathai, MS 1 1 L.V. Prasad Eye Institute, Hyderabad; and 2 Department of Community Health, Christian Medical College, Vellore, India Abstract. India, the second most populous country in the world, is home to 23.5% of the world s blind population. In 1976 India became the first country in the world to start a national program for control of blindness. All surveys in the country have shown that cataract is the most common cause of blindness and all prevention of blindness programs have been cataract-oriented. However, it has recently been recognized that the visual outcome of the cataract surgeries as well as the training of ophthalmologists has been less than ideal. There is now increasing emphasis on high-quality surgery and up-gradation of skills among ophthalmologists. Other important causes of blindness are refractive errors, childhood blindness, corneal blindness, and glaucoma. The definitions, magnitude, and present status of each of these causes of blindness, as well as efforts at control, are discussed. (Surv Ophthalmol 50:85 101, Elsevier Inc. All rights reserved.) Key words. blindness definition cataract childhood blindness corneal blindness, glaucoma national program for control of blindness (NPCB) refractive errors Introduction India is a large country that spans over 3 million square kilometers. It is home to over a billion people (22.5% over the age of 40 years), and is the second most populous country in the world. India is divided into 35 states including union territories (Fig. 1) (GDP data available from cabs/india/indiach1.htm; Accessed on 3 Jan 2004). As 16.1% of the global population resides in India, any health problems afflicting its inhabitants can be a significant cause of global morbidity. For example, it is estimated that 23.5% of the world s blind population lives in India. 160 An increase in the population especially those aged over 50 years (12.3% of India s population in 1991), has resulted in an increase in the number of cataracts, 162 glaucoma, 77 and diabetic retinopathies. 115 Further, there is every possibility that the situation is going to get worse (map of India and population details available from Accessed on 3 Jan 2004). 6,170 Although the situation appears grim, several public health successes internationally provide cause for optimism: India has been free of smallpox since 1975, 14 the world community is handling the problem of onchocerciasis admirably, 52 and there have been major strides in the control of trachoma and vitamin A deficiency across the world, including India. 86,147,148 The Government of India (GOI) is also committed to the prevention of blindness. The first organized national efforts in the prevention of blindness in India started in 1963 with a trachoma control program. 120 In 1976 India became the first country in the world to start a national program for control of 2005 by Elsevier Inc. All rights reserved /05/$ see front matter doi: /j.survophthal

2 86 Surv Ophthalmol 50 (1) January February 2005 THOMAS ET AL In this article we will attempt to review the critical ophthalmic care issues in India. These include the magnitude of the problem, health economics, specific diseases that cause the maximum morbidity and human resource and infrastructure development. In those areas where the published literature is lacking, we have relied on official reports issued by the GOI. This article will deal with only the common causes of ophthalmic morbidity in India. Fig. 1. The 35 states and union territories in the Indian subcontinent. blindness (NPCB). 3 This program has been constantly evaluated and upgraded over the years (Survey of Blindness in India, , in: Present status of National Program for Control Of Blindness. Ministry of Health and Family Welfare, 1992; pp 1 6; and National Survey on Blindness and visual outcomes after cataract surgery, : Report published by National Programme for Control of Blindness, Ministry of Health and Family Welfare). In 2000 India had a gross domestic product (GDP) per capita of US$ 457 (GDP data available from Accessed on 3 Jan 2004). About 260 million (34.7%) of the Indian population fell below the international poverty line (defined as lower than US$ 1 per day) (poverty statistics available from infochangeindia.org/poverty_indicators-indiastats.htm; Accessed on 3 Jan 2004). Poverty rates varied from 3.48% to 47.15% between states. The total expenditure on health is 5% of the GDP; 13% of this comes from the public sector and 87% from the private sector (The World Health Report 2000, Statistical Annex, p. 193). A minority of the population can afford any expenditure for their health care. Ocular complaints, presbyopia, and the need for glasses automatically bring the urban rich to an ophthalmologist. The private sector is readily available to the rich, and perhaps the urban poor, but more than three-fourths of those below poverty line reside in the rural areas. 27 Any meaningful intervention (both ophthalmic and otherwise) has to therefore target the rural poor. Prevalence of Blindness There are several surveys that report on visual impairment and blindness. 6,16,20,82,90 The definitions of blindness followed by the NPCB are different from that used by the World Health Organization (WHO). Use of the best corrected versus presenting visual acuity (VA) compounds the problem of comparison between studies. The Indian Council of Medical Research (ICMR) carried out a collaborative study on blindness during the years Blindness was defined as a best corrected visual acuity of 6/60( 20/200) with both eyes open. 6 The prevalence of blindness was estimated to be 1.38%; it varied from 0.44% to 2.8% in different states in the country. Cataract (55%) was the major cause of blindness. 6,16,90 Another survey conducted by the NPCB-World Health Organization (NPCB-WHO) in found that the prevalence of blindness (presenting VA 6/60 [ 20/200] in the better eye) had increased to 1.49%(Mohan M. Survey of blindness in India Present status of the National Programme for the control of blindness, Ministry of Health & Family Welfare, Government of India, New Delhi, 1992:80 100). Cataract now accounted for 80.1% of blindness; other causes included refractive errors, glaucoma, trachoma, and central corneal opacities. 6,16,20,82 The prevalence of blindness varied considerably between states (Table 1 and Fig. 1). It was lower in urban (1.49%) versus the rural areas (1.63%) and higher among females (1.60%) as compared to males (1.42%). 6 The proportion of blind persons from the one-fourth of the population residing in urban areas was 17.6%; 82.4% of the blindness stemmed from the 74.3% who lived in rural areas. (Present status of the National Programme for the control of blindness, 1993, Ministry of Health & Family Welfare, Government of India, New Delhi). During 1998 to 1999, the World Bank and NPCB (WB-NPCB) conducted surveys of adults over the age of 50 years in two states, Rajasthan in North India and Tamil Nadu in South India, to assess the prevalence of cataract related blindness and the related surgical outcomes. This was conducted in Bharatpur in

3 PRESENT STATUS OF EYE CARE IN INDIA 87 TABLE 1 Prevalence and Distribution of Blindness in the Various States and Union Territories (VA 6/60) Category Prevalence (%) States Low Less than 1 Punjab, Himachal Pradesh, Delhi, West Bengal, and North Eastern States Moderate Gujarat, Haryana, Kerala, Bihar (including Jharkhand), Karnataka, Andhra Pradesh, and Assam High Maharashtra, Orissa, Tamil Nadu, and Uttar Pradesh (including Uttaranchal) Very High 2 and above Madhya Pradesh (including Chattisgarh), Rajasthan, Jammu, and Kashmir Derived from WHO-NPCB Survey 1986, Mohan M. Survey of blindness in India Present Status of the National Programme for the Control of Blindness. Ministry of Health & Family Welfare, Government of India, New Delhi, 1992: Rajasthan and Sivaganga in Tamil Nadu. 110,111,157,158 The presenting VA was 6/60 ( 20/200) in both eyes in 11.9% (95% Confidence Interval [CI]: %) of the sample in Rajasthan; 6.1% (95% CI: %) remained so despite correction. 111 In Tamil Nadu 6.0% (95% CI %) had a presenting VA 6/60 ( 20/200) in both eyes and 2.5% (95% CI %) remained so even after correction. 157 These surveys in Rajasthan and Tamil Nadu were part of a nationwide survey to evaluate the magnitude and causes of blindness and cataract surgical outcomes. Thirteen other randomly selected districts from 13 states in India were covered during the period These included six World Bankassisted states (Andhra Pradesh, Chattisgarh, Madhya Pradesh, Maharashtra, Orissa, and Uttar Pradesh) and seven other states (Bihar, Gujarat, Himachal Pradesh, Karnataka, Kerala, Punjab, West Bengal). The overall prevalence of blindness as per the NPCB definition (presenting VA 6/60 [20/200] in the better eye) in those over the age of 50 years was 8.5% (95% CI: %). Higher prevalence of blindness was seen among females, individuals over 70 years, illiterates, and those residing in rural areas. Cataract was the commonest cause of blindness (62.6%) followed by uncorrected refractive errors (19.7%). The other causes included glaucoma (5.8%), posterior segment diseases (4.7%), surgical complications (1.2%), and corneal opacity (0.9%). (National Survey on Blindness & Visual Outcomes after Cataract Surgery , National Programme for Control of Blindness, Ministry of Health & Family Welfare). The results from these three surveys are summarized in Table 2. Cataract was the most common cause of blindness in Rajasthan, Tamil Nadu, and all other reported surveys. 68,111,126,135,144,145,157 The Andhra Pradesh Eye Disease study (APEDS) was a large population-based epidemiological study conducted in the state of Andhra Pradesh in south India between 1996 and ,36,37,44,49 It has provided the most valid data on ocular morbidity in India to date. APEDS reported the results of 10,293 individuals selected through a multi-stage sampling procedure from 24 urban and 70 rural clusters, from one urban and three rural areas of the state. 36,44 The prevalence of blindness (presenting VA 3/60 [ 20/400] or central visual field 10 degrees) was 1.34% (95% CI %). Presenting VA 6/60 ( 20/200) or central visual field of 20 degrees in the better eye was found in 1.84% (95% CI %). 36,44 Moderate visual impairment (presenting VA 6/18 6/60 [ 20/60 20/200] in the better eye) occurred in 8.1% (95% CI %). 44 Cataract was the commonest cause of blindness, accounting for 44% of blindness in the entire state and nearly 30% in the urban areas; 34 the other major treatable cause was refractive errors (16.3%). 36,44 Preventable corneal disease (7.1%), glaucoma (8.2%), complications of cataract surgery (0.04%), and amblyopia (4.3%) caused 19% of the blindness. 36 Treatable causes accounted for 85.7% of moderate visual impairment. 33,44 Increasing age, decreasing socioeconomic status, female sex, and residence in rural areas were associated with higher risk of blindness. 34,36,37,44,45 Projection of APEDS data estimated the number of blind people in India in 2000 to be 18.7 million (95%CI ); if the current trend continued, this number was expected to increase to 24.1 million (95% CI ) in 2010 and 31.6 million (95% CI ) by ,44 Economic Burden of Blindness The economic burden of blindness in India for the year 1997 using the cost-of-illness methodology was calculated to be US$ 4.4 billion; the cumulative loss over lifetime of the blind was estimated at US$ 77.4 billion. 140 The direct loss of gross national product due to blindness in India (for 1997) was US$ 4.0 billion. The indirect loss for both adult and children was calculated to be US$ 0.70 billion. 140 The cumulative loss due to preventable or curable blindness, for the lifespan of the blind was estimated at US$ 52.5 billion; this is 67.8% of the total cumulative loss due to blindness. 140 To calculate the economic burden of blindness the WHO definition of blindness (VA 3/60 [ 20/400] in the better eye) was used. 140

4 88 Surv Ophthalmol 50 (1) January February 2005 THOMAS ET AL TABLE 2 Causes of Blindness in India in the Three National Surveys ICMR ( ) WHO/NPCB ( ) National Survey ( ) No. Cause % % % 1 Cataract Trachoma NA 3 Small pox Malnutrition NA 5 Injuries 1.5 NA NA 6 Glaucoma Corneal opacities NA Refractive errors NA Other infections 15.0 NA NA 10 Posterior segment NA NA Surgical complications NA NA PC opacity NA NA Other causes NA Not available. Source: Present status of National Program For Control of Blindness 1993 and National Survey on Blindness & Visual Outcomes after Cataract Surgery, ; Directorate General of Health Services, Government of India, New Delhi. Cataract The population at risk for cataract blindness (50 years and above) increased from 63 million in 1971 to 115 million in 1991, 125 million in 1995, and is expected to increase to over 200 million by the year Risk factors reported from India include diarrhea, heat stroke, exposure to sunlight, undernutrition, smoking, and elevated systolic blood pressure. 12,19,69,75,105,106,131,146 The prevalence of cataract blindness (VA 3/60 [ 20/400] in the better eye with the available correction) was estimated to have increased from 2.4 million at the time of the first ICMR survey in 1974 to 4.3 million by the time of the second survey in A rapid assessment of cataract blindness (using visual acuity and or distant direct ophthalmoscopy/torchlight) around the country in the 1990s ( ) also reported the increased prevalence of cataract blindness over the years. 11,89,92,96,167 In contrast to the above reports of a significant increase in cataract blindness, APEDS determined the prevalence of cataract blindness (VA 6/60 [ 20/200] to be 0.81% [95% CI ]) with cataract responsible for 44% of blindness in the state. 36 The surveys to assist planning and evaluation of the WB-assisted cataract blindness control project undertaken in two of the beneficiary states (states that received a loan from WB for cataract blindness control) showed that cataract was the principal cause of blindness in one or both eyes in 67.5% of blind persons in Bharatpur and 69.4% in Sivaganga. 111,157 Random selection of clusters was used to identify a cross-sectional sample of persons 50 years or older. An earlier publication from Rajasthan had reported a similar percentage (43.7%) for cataract blindness. 135 The proportion of cataract blindness in the above reports is remarkably similar. INCIDENCE A population-based longitudinal study from central India provided direct estimates of age-specific incidences of blindness from cataract in India: an estimated 3.8 million persons become blind from cataract each year in India (95% CI million). 104 Persons over the age of 35 years were examined in 1982 and again in This study used distant direct ophthalmoscopy for the diagnosis of cataract. 104 A theoretical calculation from age-specific prevalence data in Haryana, a north Indian state estimated the yearly incidence to be 4,600 per million population. 21,162 The NPCB-WHO survey in has shown that there is a backlog of over 22 million blind eyes (12 million blind people) in India. 82,162 As per the study estimates, in the rural areas, there were 7.5 million mature cataracts. 54,163 Based on this report and the above incidence figures, it was estimated that in order to impact the backlog and incident cases, the country would need to operate on at least 3 4 million 82 and up to 5 6 million cataracts annually, as against the present rate of 1.7 million per year. 162,163 The above figures may be an overestimate: the incidence study used distant direct ophthalmoscopy (DDO) for diagnosis of cataract. 104 Given the validity of DDO, this is likely to be a 60% overestimate APEDS confirmed that cataract blindness had been overestimated. Dilated fundus examination and visual field testing are necessary to rule out noncataract causes of blindness such as glaucoma, retinal

5 PRESENT STATUS OF EYE CARE IN INDIA 89 diseases, or optic atrophy. Without dilated fundus examination and visual field testing, APEDS would have overestimated cataract blindness by 76.7%. 34 Based on their findings the APEDS group emphasized that the current cataract oriented eye care policy alone was inadequate to deal with blindness in India. 34 COST OF CATARACT SURGERY The cost of treating cataract blindness in India (at 1997 costs) was calculated to be US$ 0.15 billion. 140 The cost of consultation varied from $1 to $10. Cataract surgery cost $10 to $ Some estimates are much cheaper probably because estimates of physiscian reimbursement are low and the cost of intraoperative management of complications may not be considered. 164 The approximate cost of domestic intraocular lens (IOL) is about $5 whereas an imported PMMA IOL costs $22. The cost of domestic foldable IOL is about $26 whereas an imported one ranges from $55 to $133. In a study comparing the cost of extracapsular cataract surgery (ECCE) and smallincision cataract surgery, the average cost for both have been shown to be the same. 61 A survey among Indian ophthalmologists in revealed that over 61% of the cataract operations were performed in private facilities. Of these, 65% received ECCE, 41% received an IOL, and 3.4% underwent phacoemulsification. In the government facilities intracapsular cataract extraction (ICCE) was still the most common in 62% of cases. 67 Given certain assumptions, even if 52% of cataract blind in India in 1997, were treated with an investment of US$ 0.15 billion the savings in the annual GNP would be US$ 1.1 billion. 140 CATARACT PROGRAMS National Program for Control of Blindness (NPCB) Since its inception the NPCB has been involved in the control of cataract blindness. Its efforts have been supported by the non-governmental organizations (NGOs), both national and international. In order to reduce the large backlog of cataract blindness, especially in the underserved areas, the initial strategy was to perform large numbers of cataract operations in eye camps. 15,97 100,121,128,166 Surgery was usually performed in school buildings or other premises specially prepared to function as makeshift operating rooms. The goal was to work toward enough infrastructure in the form of fixed facilities (hospital based) and to eventually operate only in these operating rooms. 132 The operations undertaken in eye camps were mainly ICCE. 23,119 Over the years ( ), ECCE became the preferred technique, but the camp approach continued well into the 1990s. 24 Nearly 50% of all cataract operations performed in India were performed in such eye camps. 6,107 Cataract operations in towns were invariably performed in fixed facilities. Surgical camps were performed in rural areas and in towns, too, whenever the need arose. The surgical eye camp approach had been considered cost-effective, 114 but this is debatable as complications and inadequate outcomes are more likely in this setting. 143 The current strategy is to screen such camp patients, and bring them in for surgery in fixed facilities. 116 The government has issued guidelines discouraging surgical eye camps; the concerned chief medical officer permits such camps only in the most remote areas and that too after consent (personal communication, India Ministry of Health). Screening eye camps with patients transported to fixed facilities are encouraged. 101 The operation site may have shifted to fixed hospital facilities, but there is a danger of the camp philosophy persisting: camp patients screened and brought in for surgery may still be operated on en masse on a specified day without following the usual operating room protocols which are in place on other non-camp days. To benefit from a move to fixed facilities, it may be desirable to spread the camp patients over regular operating lists. World Bank Assisted Cataract Blindness Control Project The government of India embarked on a World Bank assisted cataract blindness eradication project in seven states (Andhra Pradesh, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Tamil Nadu, and Uttar Pradesh) at a total cost of $135.5 million. 80,82,111,163 The goal was high-volume, high-quality (ECCE) techniques especially for the underprivileged. Training to convert to ECCE surgery was part of the program. The states were chosen on the basis of the existent high prevalence of cataract accounting for approximately two-thirds of the blind population of the country (one-fourth of the world). This project started in 1994 and was meant to end in Vision 2020 This is an ambitious program of global cooperation, which embodies a joint effort by the WHO, the International Agency for Prevention of Blindness (IAPB), and international government organizations working with the governments around the world to eliminate preventable blindness by the year Vision 2020 focuses on three specific areas: disease control, human resource development, and infrastructure strengthening. 159 Cataract is one of the specific diseases targeted by this program. 56 Vision 2020 was launched in India on October 10, 2001;

6 90 Surv Ophthalmol 50 (1) January February 2005 THOMAS ET AL the ministry of health is developing its future plans accordingly (personal communication, India Ministry of Health). CATARACT SURGICAL PERFORMANCE India performed an estimated 0.5 million cataract operations in 1981 and This increased to 2.2 million in and 3.1 million in ,56,91 A recent Indian governmental estimate projects the number of cataract operations to be about 3.7 million by the year 2002 and 4 million by 2003 (personal communication, India Ministry of Health). The cataract surgical rate (CSR), defined as the number of cataract operations per year per 1 million population, was estimated to be 3,100 in Others have estimated the CSR to be lower. 95 The CSRs in some other countries are shown in Table For the eradication of cataract blindness, operations reflecting the CSR should be performed on eyes that are blind from cataract. In practice, many operations are performed on eyes that are not blind by definition or on second eyes (one eye with cataract and other eye with good vision following cataract surgery). Also, considering the failure rates that have been reported following cataract surgery from different parts of India, 5,32,88,110,143 the cataract surgical rate does not necessarily represent sight restoration. The term sight-restoring cataract operations more accurately represent surgery that eliminates blindness. PATTERN OF CATARACT SURGERY Results of a questionnaire circulated among 4,356 members of the All India Ophthalmological Society, in 1993, provided data about cataract surgical practices among Indian ophthalmologists. 66 Surgeons performed an average of 500 operations per year. The majority (82.8%) reported doing some ECCE procedure but the most commonly used procedure among both private and government hospitals was WHO Region TABLE 3 Cataract Surgery Rates (CSR) CSR (cataract operations / million population / year China 200 Africa 300 South East Asia 1000 (excluding India) India 3100 Western Europe 4000 Australia and Japan 4000 North America 5500 Estimates for still ICCE. On an average, the private sector performed 67% of all cataract operations. The response rate was only 49%. Those who responded were likely to be the more progressive practitioners who were prepared to report their experience. Ophthalmologists operating on patients in government facilities appear to be under-represented. This poor and selective response rate to the questionnaire makes it difficult to generalize the results. 66 A second survey conducted in 1995 included members of the All India Ophthalmological Society (AIOS) and various state ophthalmic societies who were not AIOS members. 67 Out of the 6,800 members surveyed only 31% responded. The number of operations per private practice surgeon per year averaged 396, whereas government practice and the composite practice surgeon averaged 419 and 860, respectively. Over 85% surgeons reported some experience with ECCE and IOL. As the response rate to the survey was poor and likely to be biased, the article s conclusion that ECCE is more common in India than is generally recognized probably need further substantiation. According to NPCB-INDIA (Quarterly newsletter of NPCB and Vision 2020: The Right to Sight Initiative, July September, 2003) the number of surgeons trained in ECCE/IOL surgery under NPCB has increased from 191 prior to year 2000 to 1,363 during the period Recent articles out of India (and courses at various conferences) indicate a trend toward small-incision surgery; manual as well as phaco. 61,62,150 The articles, however, may not be representative of the average ophthalmologist. CAUSES FOR LOW UPTAKE AND UTILIZATION OF EYE CARE SERVICES Uptake of eye care services refers to usage or utilization of available eye care services by potential beneficiaries. In India, only about 30% of patients who are bilaterally blind from cataract receive surgical treatment; the rest remain blind for the rest of their lives. 90 The utilization of infrastructure, beds, and manpower is estimated to be less than 40%. 90 The barriers to cataract surgery include poverty, lack of transportation, gender-related factors, and lack of awareness, accessibility, and cost. 47,70,161 Men were more likely to attend the camps than women, and women availed surgery at a later stage. This may be related to the lower literacy rate among women, higher social standing and a perceived role of men as decision-maker. 6,161 Fear (damage to eyes, fear of death), family responsibilities, and a fatalistic attitude were the other reasons cited. Most patients did not travel more than kilometers to access eye care facilities 6,71,168 In a study conducted to investigate service uptake in a rural Indian population, only 6.8%

7 PRESENT STATUS OF EYE CARE IN INDIA 91 of the adults with visual problems attended camps. Of those who did not attend, 43.8% had low vision (VA between 6/18 to 3/60 [20/60 to 20/400] and 6.9% were blind ( 3/60 [ 20/400]) in both eyes. 55 APEDS reported accessing of eye care services by those with vision 6/18 [ 20/60] in the whole state. Only about one-third of those over 15 years of age with visual impairment had utilized the eye care services. 44 Brilliant et al conducted a field trial to compare the effects of four health education strategies each coupled with two economic incentives (partially and totally free services) on the awareness and acceptance of cataract surgery. 22 One of the heath education strategy, house-to-house visit by an aphakic motivator had increased acceptance over others. Of the economic incentive interventions, those that were totally free had higher surgery acceptance rates. 22 OUTCOMES The number of operations done generally measures performance. A pilot project in the district of Bihar was evaluated for functioning of district blindness control societies (DBCS). The number of cataract surgeries performed was reported to have increased over a 3-year period from 600 to 4,000 per year. 93 The total number of cataract operations performed between April 2002 and March 2003 in all the states of India were 3,857,112. Of these 77% had IOL implantation (NPCB-INDIA). However, there are not many reports of the actual visual outcomes following cataract surgery. The percentage of blindness following cataract surgery in India ranged from %. 5,29,88, 110,134,143,158,168 Blindness following cataract surgery has been defined as visual acuity 3/60 [ 20/ 400] 5,134,168 in some surveys whereas others defined it as visual acuity 6/60 [ 20/200]. 88,110,158 The wide range reported here are due to the varying definitions of blindness and also due to the fact that the visual acuity was recorded at varying durations after the cataract surgery (ranging from 4 6 weeks to years). The assessment of outcome of cataract surgery in several states was recently published by the NPCB (Assessment of Outcome of Cataract Surgery: Results of the Survey between April 1998 to March A publication of the National Programme for Control of blindness, Ministry of Health & Family Welfare, Government of India). The study analyzed cataract surgical records introduced in 1997 and most states were found to have success rates above 70%. However, although the inclusion criteria for cataract surgery was visual acuity of 6/60 [20/200] or less, success was defined as visual acuity better than 3/60 [20/400]. The Rajasthan state survey, which was part of the World Bank assisted cataract blindness control project, reported that 12.8% (549/4280) of the examined population had undergone cataract surgery. 111 Ninety-two percent of the patients had undergone ICCE and 3 out of 5 had surgery in a camp; 44.1% of the operated eyes had presenting visual acuity 6/ 60 [ 20/200] whereas 14.0% of eyes had best corrected visual acuity 6/60 [ 20/200]. Vitreous loss was the most common complication noted. 110,111 A similar survey in Tamil Nadu reported that 14.7% of the examined population had undergone cataract surgery and 13.4% had undergone ECCE; % of the operated patients had presenting visual acuity 6/60[ 20/200] and 25.2% better than or equal to 6/18[20/60] in both eyes. 157,158 The overall visual outcome after cataract surgery from the national survey from showed that 33.6% had presenting vision 6/60 [ 20/200] after cataract surgery. Best correction reduced this to 15.5%. (National Survey on Blindness & Visual Outcomes after Cataract Surgery , National Programme for Control of Blindness, Ministry of Health & Family Welfare). An assessment of visual outcomes in camp based cataract surgery from various studies in north India reported good vision ( 6/18 [ 20/60]) in 45 71% of the patients. 10,110,113 In the urban area of APEDS, 14.6% (95% CI %) of the population 50 years had undergone cataract surgery in one or both eyes. 32 Of the eyes that had undergone cataract surgery, 21.4% had very poor outcome (presenting VA or VA with refractive correction if used 6/60 [ 20/200]) and 30.5% had poor outcome (presenting VA 6/18 6/60 [20/60 20/200]). 32 The odds of blindness were significantly higher among those who had undergone ICCE, those belonging to the lower socio-economic group, and women. This could be related to the relatively disadvantaged status of women in our society, which may result in cataract surgery under more inadequate conditions and poorer postoperative follow-up. The odds of blindness were also higher if surgery had been performed in the recent past (3 or less years). Poor outcomes were attributed to the recent conversion to extracapsular and the need for high volumes to comply with targets for number of operations set by the concerned authorities. 32 The high rate of poor visual outcome (21.4% 30.5%) was predominantly due to surgery-related causes and inadequate refractive correction. 32 To improve this situation more attention is to be given to selection of cases, surgical quality, management of complications, refractive correction, and follow-up care. The present focus is more on the number than on the quality of cataract surgeries.

8 92 Surv Ophthalmol 50 (1) January February 2005 THOMAS ET AL Although the numbers of cataract operations are increasing, it is obvious that the visual outcomes need improvement. 26 The WHO provides guidelines: following cataract surgery, at least 90% should have a functional acuity of 6/18 [20/60] or better; less than 5% should have a visual acuity 6/60 [ 20/ 200], inclusive of preexisting causes. 7 The estimated incidence of blinding cataract at 3.8 million is probably an overestimate. 104,151,153 Assuming this overestimate to be 60%, the corrected incidence becomes 1.5 million. 151,152,153 Even if the incidence were higher, the current cataract surgical rate would have been enough to handle incident cases as well as the backlog. Provided of course that all operations were performed on those who were blind and did indeed restore sight.(many cataract operations are performed at visual acuities better than 6/ 60 [20/200] and on the second eye of patients who have already undergone successful cataract surgery in one eye.) It follows then that if the current surgical rate is actually good enough, we can concentrate on improving the outcomes. SENTINEL SURVEILLANCE In order to monitor the performance, outcomes, and quality control, the Government of India has recently involved the NPCB in the setting up of sentinel surveillance units (SSU). Such SSUs were set up in districts considered representative of the state/ region (Ministry of Health and Family Welfare). If effective strategies are put in place to eliminate 95% of cataract blindness by 2020, we would be able to prevent blindness in 15.6 million persons; this works out to the prevention of 78 million blind person years. 30 Refractive Errors MAGNITUDE The NPCB-WHO survey found that refractive errors were responsible for 7.35% of blindness 6 (Mohan M. Survey of blindness in India Present Status of the National Programme for the Control of Blindness, Ministry of Health & Family Welfare, Government of India, New Delhi, 1992:80 100). A population-based study from north India reported on the prevalence of refractive errors in children aged 5 to 15 years. 112 The prevalence of uncorrected, presenting, and best corrected visual acuity of 6/12 [20/40] or worse in the better eye was 6.4%, 4.9%, and 0.81%, respectively. Refractive error caused 81.7% of the visual impairment (VA 6/12 [ 20/40]). 112 APEDS reported the prevalence of refractive error (causing presenting VA 6/60 [ 20/200]) to be 0.30% (95% CI ). 36,44 Refractive errors were responsible for 16.3% of blindness ( 6/60 [ 20/200]) in the state of Andhra Pradesh. They were the leading cause of moderate visual impairment ( 6/18 6/60 [ 20/60 20/200]). 44 Two other recent surveys (WB-NPCB) 111,157 have reported that refractive errors are the second most common cause of blindness (presenting VA 6/60 [ 20/200]); and the leading cause of moderate visual impairment. 111,157 As opposed to APEDS in these surveys uncorrected aphakia has been clubbed with refractive errors. Many of those who were blind because of refractive error were aphakes without spectacles. 111 Data on economic loss due to refractive error and uncorrected presbyopia is not available. At the moment refraction and glasses are available to only those who seek help. An average pair of prescription glasses cost $7.5 20, not including consultation fees. 85 There is no program in place to address this easily correctable cause of visual impairment and blindness in the community. Blindness due to refractive error in any population suggests that the eye care services in general are inadequate. A program has to provide sufficient number of personnel to perform reasonable quality refraction and adequate infrastructure to provide affordable spectacles to these patients. 46 Addressing the blindness caused by refractive errors by 2020 will prevent blindness in 4.2 million people and 82 million blind person years. 30 Childhood Blindness Childhood blindness is defined as a best corrected visual acuity of less than 3/60 [20/400] in the better eye of a child aged less than 16 years. 57 As children have a lifetime ahead of them, the total number of blind years lived by a child is more than that of a person who becomes blind in adulthood or old age. Although the estimated number of blind children is much lower compared to the number of blind adults, the cumulative number of blind person years worldwide due to childhood blindness ranks second only to the cumulative number of blind person years due to cataract blindness. 58 Accordingly, childhood blindness contributes significantly to loss of productivity as the total number of blind years suffered by the blind child is more than those suffered by a person who becomes blind in adulthood. The prevalence of visual impairment and blindness in children varies from 0.1/1,000 in wealthy countries to about 1.1/ 1,000 in the poorer countries. 59 The prevalence in India is estimated to be 0.5/1,000 children; among neighboring countries this ranges from 0.63/1,000 in Nepal to about 1/1,000 in Bangladesh. 57,59

9 PRESENT STATUS OF EYE CARE IN INDIA 93 A house-to-house survey to identify the blind was conducted in the state of Andhra Pradesh, and 113,514 children were identified. The prevalence of blindness (defined as best corrected visual acuity 6/60 [ 20/200] in the better eye) was found to be 0.65/1000 children (95% CI /1000 children). 43 In a study on visual impairment in school children from the same state, 3.1% of 3,669 were found to have visual impairment (visual acuity 6/ 18 [ 20/60] in the better eye). 83 Among these, 0.5% had a visual acuity 6/60 [ 20/200] in the better eye. Following refraction, 94.8% of the visually impaired children improved to 6/18 [20/60] or better; none were legally blind (VA 6/60 [ 20/200]) or economically blind (VA 6/60 [ 20/200]). 83 Projecting the childhood blindness prevalence of 6.5/10,000 in the population-based study in Andhra Pradesh, to the estimated 400 million children in India, we would expect 260,000 (95% CI: 204, ,000) blind children in India. 43 Using the concept of blind person years, and assuming that blind children have a mean life expectancy of 15 years lower than the expected 63 years of the Indian population, they would live 43 years after becoming blind (assuming a mean age at onset of blindness as 5 years of age). This would result in a total of 11.2 million blind years; that attributed to cataract in adults is roughly 22.5 million blind years. 43,58 The socio-economic burden due to pediatric blindness in India (like the world over) comes close to that caused by adult blindness. 43 Childhood blindness alone accounts for 28.7% of the economic burden of blindness in India. 140 The cumulative economic loss from childhood blindness, calculated for the lifetime of 0.25 million blind children assumed to have lost 33 working years of their life amounts to US$ 22.2 billion. 140 CAUSES There are an estimated 15,000 children living in residential schools for the blind across the country and 5,000 are in integrated education programs; 1,411 children were examined from schools for the blind in nine states of the country (Gujarat, Madhya Pradesh, Haryana, Uttar Pradesh, West Bengal, Maharashtra, Karnataka, Kerala, Tamil Nadu). Severe visual impairment ( 6/60 3/60 [ 20/200 20/400]) was seen in 8.0%; and 85.4% were blind ( 3/60 [ 20/400] no light perception). 124 Corneal diseases accounted for 26.4% of blindness in children. 124 Other studies corroborated corneal causes to be most common. 25 Vitamin A deficiency was the leading cause (18.6%); measles, ophthalmia neonatorum, trauma, keratitis, and harmful traditional practices (applying plant juice) constituted the others. 124 The predominant cause of blindness varied from state to state. Thiry-one percent of the children were affected by preventable and 16.3% by treatable causes. 17,18,50,57,123,124,133 Vitamin A deficiency has been a major cause of blindness 53,102,125,138 and it is more prevalent in the rural areas. 8,53,125 Vitamin A deficiency is not only a cause of morbidity from blindness but also of morbidity and mortality from diarrhea and respiratory tract infections. Keratomalacia is a severe form of vitamin A deficiency. 50 The prevalence of blindness due to keratomalacia may be underestimated because of the high mortality associated with blinding malnutrition. 50,103 Vitamin A supplementation was proven to prevent keratomalacia in pre school children living in urban slums. 18,169 Children in six schools for the blind and in three integrated education programs in the state of Andhra Pradesh alone were examined. Two hundred sixtyseven (91.7%) were classified as being severely visually impaired or blind ( 3/60 [ 20/400]). The most common anatomical sites were cornea in 24.3% children, retina in 1.1%, and whole globe in 20.2%. 60,76 The main causes of childhood blindness identified in APEDS were congenital globe anomalies (25%) and retinal diseases (22.2%); optic atrophy, cataract, corneal diseases, and glaucoma were the others. 43,59 Amblyopia due to high refractive error was seen in 2.8% and due to aphakia in 1.4%. 43 Another study to determine the prevalence of visual impairment among school children from the same state showed that strabismus was found in 0.7%. 83 The most common cause of childhood blindness in APEDS 43,59 differed from the blind school survey. 124 The APEDS gives the prevalence in only an urban area of a single state (Andhra Pradesh) in India. The blind school survey on the other hand gives the pattern in nine blind schools across the country. The Integrated Child Development Services (ICDS) scheme is the largest national program for the promotion of the mother and child health and their development. The package of services provided by the ICDS scheme includes supplementary nutrition, immunization, health check-up, referral services, nutrition and health education, and preschool education. The distribution of iron and folic acid tablets and mega doses of vitamin A is also undertaken. The ICDS had led better utilization of services by its beneficiaries, namely children below 5 years, pregnant and lactating mothers, and other women in the age group of 15 to 44 years. 84 CURRENT STATUS The actual number of pediatric ophthalmologists in the country is not known, but they are few and far between; few hospitals are equipped or have the

10 94 Surv Ophthalmol 50 (1) January February 2005 THOMAS ET AL personnel to manage pediatric cases. 39 Although the issue has been recognized for some time, 109 currently there is no separate or special strategy for the control of childhood blindness. Children may be examined sporadically as part of school surveys done by some organizations or hospitals. There is no organized screening program for infants and children. Those with clinical problems are referred to hospitals. A comprehensive eye care approach, including epidemiological research, community-based programs aimed at targeting preventable causes of blindness, provision of curative child eye care services by trained personnel, and community-based rehabilitation programs, including low vision services and basic and clinical research for a better understanding of the causes of childhood blindness, has been proposed. 43 A practical and ongoing assessment can be obtained by linking assessment of childhood blindness with other population-based activities with wide coverage, such as vaccination of children and child survival programs. 43,147 Corneal Blindness MAGNITUDE Corneal blindness has been recognized as a public health problem. 118 The NPCB-WHO survey done across the country reported corneal opacities to be responsible for 1.52% of the blindness 6 (Mohan M. Survey of blindness in India Present Status of the National Programme for the Control Of Blindness, Ministry of Health & Family Welfare, Government of India, New Delhi, 1992:80 100). Trachoma, which accounted for 5% in the earlier ICMR survey, was found to cause 0.39% of the blindness in the WHO-NPCB survey. 6 APEDS, a population-based study among urban and rural subjects in the state of Andhra Pradesh, found the prevalence of corneal blindness to be 0.13%; 7.1% of blindness was due to corneal disease. 44 The most common cause of corneal opacities was exanthematous fever during childhood. Other causes included chemical burns, use of traditional medicines, corneal edema due to various causes, and pterygium. 34 A clinic based report from Rajasthan in 1991 attributed 15.4% of the blindness to corneal diseases. 135 In the WB-NPCB survey in Rajasthan, corneal causes (including those due to trachoma) caused 16.8% of the blindness (VA 6/60 [ 20/200]). 111 There is a regional variation in the amount of blindness attributed to corneal causes. The same survey found corneal disease to be responsible for 4% of blindness in the southern state of Tamil Nadu. 157 It is estimated that approximately 20,000 patients with corneal blindness were being added to the backlog waiting for corneal transplants each year. 41 EYE BANKING IN INDIA India s first eye bank was started in Madras (now Chennai) in 1945; the first legislation on regulation of eye donation was passed in An association of eye banks named the Eye Bank Association of India (EBAI) with its headquarters in Hyderabad was established in To study the awareness of eye donation, 2,954 subjects over the age of 15 years were included in the sample from a survey in Hyderabad city. Of these, 2,522 were interviewed by a structured questionnaire, representing a participation rate of 85.4%. 44,48 Eye donation awareness (defined as having heard of eye donation) was 73.8%. 44,48 The media (television and print, 83.3%) was the chief source of awareness. Although only 2.2% had already pledged their eyes, a further 43% were willing to do this. Willingness to donate was significantly lower in subjects 60 years of age (OR 0.3; 95% CI ). This survey was carried out from October 1996 to February ,48 In 1992, nearly 8,000 corneal transplants were performed in India. 137 By 1993 there were 166 eye banks in India; 27 of them collected more than 50 eyes per year. 137 An estimated 15,000 corneas were procured annually but a large proportion were unsuitable for transplantation. 41 In 2000, the eye bank association of India reported an annual collection of about 19,000 eyes (personal communication, Eye Bank Association of India). Information on utilization was unavailable. The requirement of donor tissue is estimated to be at least 20 times the current procurement. 41 The three factors that determine fate of corneal transplantation are quality of donor cornea, the nature of recipient pathology, and care issues. Care issues include availability of trained corneal surgeons, availability of appropriate infrastructure for corneal surgery, and follow-up care. This encompasses access to corneal specialists, medications, and appropriate visual rehabilitation. In all these areas, India has to make significant progress to improve the outcomes of corneal transplant surgery. Keeping in mind the financial constraints, a three-tier eye banking system was proposed and is currently being slowly implemented. Eye donation centers are responsible only for public awareness and tissue harvesting. Eye banks will, in addition, also perform tissue evaluation, tissue preservation, and tissue distribution, and eye banking training centers will take the responsibilities of training of eye banking personnel also. These are all interlinked. 130 Tissue Banks International (TBI), through its international division known as the International

11 PRESENT STATUS OF EYE CARE IN INDIA 95 Federation of Eye Banks (IFEB), is assisting in establishing eyebanks on a global basis. This international network of eye banks will generate eye tissues which can be shared with those parts of the world (including India) where no eye-banking system currently exists. 65 The most common indication for penetrating keratoplasty (PK) was corneal scarring. 42 Previous transplant failure, corneal dystrophies, and aphakic and pseudophakic bullous keratopathy were some of the other causes for a corneal opacity requiring PK. 40 The survival rates at 1, 2, and 5 years for 1,389 corneal transplants from a tertiary care center (L.V. Prasad Eye Institute, Hyderabad) in India were 79.6% (95% CI %), 68.7% (95% CI %), and 46.5% (95% CI %), respectively. The 5- year survival rates were highest when PK was done for keratoconus, 95.1% (95% CI %) and least 21% (95%CI %) when performed for previous transplant failure. 41 The commonest cause for graft failure reported was graft rejection (29%). The other causes were increased intraocular pressure, infection excluding endophthalmitis, and ocular surface problems. 40 Superficial and deep vascularisation of the host cornea before transplantation was associated with significantly increased risk of transplant failure. Following PK the percentage of blind eyes was reduced from 80.2% to 41.8%. 41 However, the number of bilaterally blind persons in India who are rehabilitated by a penetrating keratoplasty is not available. Glaucoma PREVALENCE OF GLAUCOMA Glaucoma is estimated to affect 12 million Indians and causes 12.8% of the blindness in the country. 122,160 Early population-based studies that did not use modern definitions or modern examination techniques reported a prevalence of glaucoma between 1.70% to 13%. 6,9,79,142,145 Two recent populationbased surveys from south India, the Vellore eye study (VES) and the Andhra Pradesh eye study (APEDS) used modern techniques for the diagnosis of glaucoma. 31,38,77 The prevalence of primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG), and ocular hypertension (OHT) in the VES were 4.1 (95% CI ), 43.2 (95% CI ) and 30.8 (95% CI ) per 1,000 population, respectively. Occludable angles were found in 10.35% of the population studied. 77 For APEDS, prevalence of definite POAG was 16.2 (95% CI ) per 1,000; 66.7% of these had IOP below 22 mm Hg. Ocular hypertension was diagnosed in 3.2 (95% CI 1 7.8) per 1,000; 92.6% of patients with definite POAG were previously undiagnosed, and 51.9% of those with definite POAG had severe glaucomatous damage. The prevalence of POAG increased significantly with age. 38 The prevalence of manifest PACG was 7.1 (95% CI ) per 1,000; that of occludable angles without ACG was 14.1 (95% CI ) per 1, Much of the difference between the two studies can be explained by definitions and methodology. 154,156 The VES excluded older age groups and had a poor response rate with resultant wider confidence intervals. The major differences between the studies were in the technique of gonioscopy and the definition of occludability of angles. 154,156 Clinic based reports emphasize the importance of secondary glaucomas. 2 The common causes include aphakic glaucoma (37.7%), lens induced (12.4%), corneal pathology (12.2%), neovascular (9.6%), traumatic (8.4), and chronic uveitis (8.2%). With the country converting to ECCE and IOL, the proportion of aphakes (ECCE) and pseudophakes with secondary glaucoma is expected to have decreased. 2 In the younger age groups, the common causes for secondary glaucoma were steroid abuse and trauma. 141 Epidemic dropsy glaucoma is reported sporadically from states that use mustard oil for cooking; this is adulterated by argemone mexicana oil. 136 Screening Versus Case Detection Screening for the disease has been proposed in the past. 108 Most Indian ophthalmologists do not practice the comprehensive eye examination as recommended by the American Academy of Ophthalmology. 4 Because intraocular pressure, disk examination, and gonioscopy are not routinely taught in residency programs (nor practiced), established glaucoma is inadvertently missed. 31,38,154 There are less than 25 glaucoma specialists in the country; most general ophthalmologists diagnose and treat glaucoma. India does not have the requisite infrastructure to categorize and follow up test positives on various screening tests let alone treat the true positives. This is true for both POAG as well as PACG. The relative lack of access to automated perimetry, optic disk photography, compounded by poor patient compliance makes glaucoma diagnosis and management far from ideal. At the moment, case detection in the clinics of ophthalmologists where people at high risk gather for other eye care needs is probably the way to go. Most newer antiglaucoma medications are available in the country, but cost limits their use. The threshold for surgical treatment is lower; mitomycin is sometimes used primarily. Good short-term results