Primary Eye Care Services Research Articles

A randomised controlled trial to investigate effects of enhanced supervision on primary eye care services at health centres in Kenya, Malawi and Tanzania.

BackgroundKnowledge and skills of primary health care workers (PHCWs) in primary eye care have been demonstrated to be inadequate in several districts of Kenya, Malawi, and Tanzania. We tested whether enhanced supervision, focused on improving practical skills over two years, would raise the scores of these workers on a test of basic knowledge and skills.MethodsThis was a randomised controlled trial. All primary health care (PHC) facilities within two districts of each country were enrolled and randomly assigned by district (Kenya, Malawi) or by health care facility (Tanzania) to receive quarterly skills-based supervision by a district eye coordinator or to continue existing routine supervision. At baseline, a test of basic knowledge and skills in five key areas was administered to PHCWs, and visual acuity (VA) charts and working torches were provided. After two years the test was administered again. Changes in test scores were compared between the intervention (enhanced supervision) and the non-intervention (routine supervision) facilities.ResultsAll 137 facilities in the six districts were enrolled including 343 PHCWs. At baseline, no facility had a visual acuity chart and 18 (13%) had a working torch; the average total skills scores were 6.04 and 6.38 (maximum of 12) in the non-intervention and the intervention facilities, respectively. After two years, 16 intervention facilities (23.2%) had a visual acuity chart correctly placed and 19 (27.5%) had a working torch, compared to 4 (5.9%) and 6 (8.8%), respectively, in the routine supervision facilities. At the facility level, the change in overall test scores was +1.84 points in the intervention sites compared to +0.42 points in the non-intervention sites (p<0.001). Staff turnover included about 75% of the staff by the end of the study.ConclusionThe improvements in the enhanced supervision facilities were very modest and of questionable clinical significance. The low impact of the intervention may be due to the high turnover of PHCWs or high absenteeism. A better understanding of the quality of eye care at PHC facilities and influencing factors are urgently needed before continuing to invest resources in the scale up of this model of task shifting in Africa.

Traditional eye medicine practice in Benin-City, Nigeria

The use of traditional eye medicines as a form of eye care in Africa is very common. However, there is concern about the harmful effects of some traditional medicines on the eyes. This study was a cross-sectional survey conducted in Benin-City, Edo state, Nigeria. Sixty-eight traditional medicine practitioners (TMPs) who treated eye conditions participated in this study. Most (87%) were males and 13% were females. Their age ranged between 25 to 65 years with a mean age of 42.25 ± 2.14 years. Information was obtained through one-on-one oral interviews and a structured questionnaire consisting of open-ended questions. The most common method of training (46%) was by father-to-son tutelage. Conjunctivitis, itching and poor vision were the most common conditions treated by all practitioners. The majority of the TMPs (62%), practiced full time while 38% practiced part time. Forty six percent considered patients’ case histories as more important than physical examination of the eye while 54% felt both history and examination were equally important. Thirty-six percent of practitioners reported inverting the upper eyelids as part of their examination. Couching of cataracts was done by 38%. While 49% had referred ‘difficult’ or ‘stubborn’ cases to orthodox hospitals, 51% had never referred a case. Traditional healers are well accepted in their communities and will continue to be consulted by the people. Health education programs with emphasis on safe eye care practices need to be established for traditional healers. Working with healers and training them to recognize cases needing urgent referral and encouraging the use of non-harmful practices may provide a more sustainable health care structure in the community. Cooperation between these two aspects of medicine is extremely important for the provision of primary eye care services in rural Africa. (S Afr Optom 2013 72(4) 167-172)

A collaborative approach to improving access to primary eye care services in five sites across the United Kingdom 2011 to 2013

A collaborative approach to improving access to primary eye care services in five sites across the United Kingdom 2011 to 2013

Scaling up the delivery of refractive error services within a district health system: the KwaZulu-Natal, South Africa experience

BackgroundIn South Africa, the health service is based on a Primary Health Care (PHC) philosophy with the District Health System (DHS) as the locus of delivery. However eye care services, particularly primary eye care, refractive error and low vision, have not been prioritised accordingly. Hence the aim of the Giving Sight to KwaZulu-Natal (GSKZN) project was to integrate the delivery of eye care services into the district health system, with emphasis on addressing the need for uncorrected refractive error and low vision services.The project was implemented in the KwaZulu-Natal province, South Africa, to scale up the delivery of refractive error services utilising a four pronged approach; including advocacy, human resource development, equipment provision and research.MethodsThis paper is a description of the project and a retrospective analysis of data received through the course of the project from July 2007 to June 2011. Data were collected from training registers, equipment schedules and service delivery reports from institutions. Reports from the data base were then analysed and achievements in training and trends in service delivery were determined.ResultsOver a four year period (July 2007 and July 2011) 1004 persons received training in rendering eye health services appropriate to their level of deployment within the DHS. During the course of the project, these 1004 persons examined 1 064 087 patients. Furthermore, the total number of clinics offering primary eye care, refractive error and low vision services increased from 96 (10%) to 748 (76%). With increased numbers of PHC Nurses trained in primary eye care, a subsequent decrease of 51.08 percent was also observed in the number of patients seeking services at higher levels of care, thus streamlining eye health service delivery.ConclusionThis project has shown that scaling up can occur in delivering eye health services within a health district, through a multi-faceted approach that encompasses focused training, advocacy, development of appropriate infrastructure and the development of referral criteria with clear guidelines for the management of patients.

A vision for optometry in Oman

A vision for optometry in Oman

Turning the tide of corneal blindness

Corneal diseases represent the second leading cause of blindness in most developing world countries. Worldwide, major investments in public health infrastructure and primary eye care services have built a strong foundation for preventing future corneal blindness. However, there are an estimated 4.9 million bilaterally corneal blind persons worldwide who could potentially have their sight restored through corneal transplantation. Traditionally, barriers to increased corneal transplantation have been daunting, with limited tissue availability and lack of trained corneal surgeons making widespread keratoplasty services cost prohibitive and logistically unfeasible. The ascendancy of cataract surgical rates and more robust eye care infrastructure of several Asian and African countries now provide a solid base from which to dramatically expand corneal transplantation rates. India emerges as a clear global priority as it has the world's largest corneal blind population and strong infrastructural readiness to rapidly scale its keratoplasty numbers. Technological modernization of the eye bank infrastructure must follow suit. Two key factors are the development of professional eye bank managers and the establishment of Hospital Cornea Recovery Programs. Recent adaptation of these modern eye banking models in India have led to corresponding high growth rates in the procurement of transplantable tissues, improved utilization rates, operating efficiency realization, and increased financial sustainability. The widespread adaptation of lamellar keratoplasty techniques also holds promise to improve corneal transplant success rates. The global ophthalmic community is now poised to scale up widespread access to corneal transplantation to meet the needs of the millions who are currently blind.

Key factors determining success of primary eye care through vision centres in rural India: Patients′ perspectives

Aim:This paper intends to discuss the patients’ perspective on the determinants of primary eye care services from vision centers (VC) in rural India.Materials and Methods:A retrospective study design and interview method was used on 127 randomly selected patients who accessed the 4 VCs in 2007. Factor analyses and linear regression models were used to predict the associations with patient satisfaction.Results:The three factors derived from factor analyses were: (1)-vision technician (VT), (2)-location of VC, and (3)-access to VC; explaining 60% of the variance in total patients’ satisfaction with VC. The first model (R2: 0.61; F1,124=144.36, P<0.001), indicated that respondents who had ‘difficulty to travel to the place of VC’ and those who can afford to pay had less satisfaction with VT services. The second model (R2=0.18; F1,124=29.5, P<0.001) explained that respondents’ difficulty to identify the building of VC had decreased patients’ satisfaction and the third model (R2=0.36; F1,124=45.6, P<0.001) indicated that those who had to travel<5 km to the VC and had 0.38 units of increased satisfaction level with the services of VC.Conclusion:A good VT can enhance patient satisfaction. However, patient expectations are not only confined to the provider but also other factors such as ability to pay and convenient transportation that helps patients reach the location of the VC with ease.

Braille use among Norwegian children from 1967 to 2007: trends in the underlying causes

The aim of the study was to estimate the occurrence, diagnoses and time trends among Norwegian children that have received education in braille from 1967 to 2007. We used a retrospective population-based study design. The health care system is free for all inhabitants in Norway. We included all children that had received braille education the last four decades. From each student's record, we abstracted year born, country of birth, gender, year diagnosed, diagnosis, classification of visual impairment and type of reading media. We identified 287 children (137 girls and 150 boys) that had received braille education over the last 40 years. Of these, 262 (91.3%) children were born in Norway, 145 (53.7%) were diagnosed within the first year of life and 59 (20.6%) from age of one to five. The most frequent diagnoses were Retinopathy of Prematurity (ROP), Juvenile Ceroid Lipofuscinoses (JNCL), Lebers Congenital Amaurosis (LCA) and Retinitis Pigmentosa (RP). Among the children, 63% (N = 170) used braille only, 9% (N = 25) braille and print, but priority braille, and 27% (N = 73) braille and print, priority print. The number of children with ROP using braille had a peak in 1977, then the number declined. The number diagnosed with LCA increased from 1987 to 1992. The number of braille users among children diagnosed with JNCL tended to increase substantially after 1992. Braille education seemed to be dependent of trends in diagnoses as well as trends in recommendations from professional educators.

A glaucoma equity profile: correlating disease distribution with service provision and uptake in a population in Northern England, UK

Glaucoma is a significant health problem, with associated inequalities. Equity profiles are an established public health tool to examine the scale of health inequalities and to imbed action into the commissioning cycle. This is the first equity profile conducted in the United Kingdom for an ophthalmic condition. This methodology also provides a model for use in other localities and for other eye conditions. Existing services were mapped and need identified. A wide variety of data sources were analysed. Mapping was undertaken using Mapinfo Professional Geographical Information Systems software. Statistical analysis was conducted using Microsoft Excel 2003. No single data source provided a fully informed perspective. A clear mismatch between areas of deprivation and location of optometry was observed. Secondary analysis of electronic patient records revealed a significant association between 'late presentation' and older age (mean age of late presenters=76.4 years, 95% CI=75.1-77.6 compared with earlier presenters, 72.4 years, 95% CI=71.7-73.1). Late presentation was also associated with living in an area of high deprivation (chi(2)=7.1, df, P<0.05). Ethnicity data was poorly recorded. Qualitative data provided invaluable insights. Increasing access to services involves collaboration with optometrists, ophthalmologists, public health, and commissioners. It is no longer acceptable to rely on private high street optometry to provide primary eye care services in areas of high need. Outreach services must be developed and evaluated in areas of relative deprivation if world class eye services are to be achieved.

An Estimate of Patient Costs and Benefits of the New Primary Eye Care Model Utilization Through Vision Centers in Andhra Pradesh, India

Little or no work has been carried out in developing countries on costs to patients and patient benefits in accessing primary eye care services. The purpose of this study was to assess the indirect, direct, and overall costs of patients accessing vision care at vision center services (New Primary Eyecare Approach) as compared with the nearest private clinic. The authors used a standardized questionnaire and a paired sample t test to check the significance of difference of costs. They considered a P value of <.05 as significant in this study. The total costs were significantly lower for patients who accessed the vision centers compared with the costs these patients may have incurred if they had sought services from the nearest town-based clinic (mean in Indian rupees [INR] of 178.4 ± 48.3, standard error of the mean = 4.2, and INR 366.2 ± 48.2, standard error of the mean = 4.2, respectively, t test P value < .001). vision centers, besides providing quality eye care services, offer substantial cost savings to rural populations compared with town-based optical clinics.

Novel optometrist-led all Wales primary eye-care services: evaluation of a prospective case series

Aims:To derive an evidence base for the efficacy of two novel optometric primary eye care services in Wales, the Primary Eyecare Acute Referral Scheme (PEARS) and the Welsh Eye Health...

Exploring glaucoma awareness and the utilization of primary eye care services: community perceived barriers among elderly African Caribbeans in Chapeltown, Leeds

Exploring glaucoma awareness and the utilization of primary eye care services: community perceived barriers among elderly African Caribbeans in Chapeltown, Leeds

A Community-Based Trachoma Survey: Prevalence and Risk Factors in the Tigray Region of Northern Ethiopia

Aim: Trachoma is a public health problem in Ethiopia accounting for 35–50% of cases of blindness. This study aims to determine the prevalence of trachoma in Tigray and to evaluate whether common risk factors are also risk factors in this region. Method: A cross sectional community-based survey was conducted. From six districts, a total of 48 villages were selected by a multistage cluster random sampling technique. A total of 3900 people who were selected randomly from 1200 households were assessed for signs of trachoma. Ophthalmic nurses used a simplified clinical grading system to assess stages of trachoma while environmentalists assessed risk factors for trachoma. Results: Of the 3900 people examined, 13% had trachomatous follicles (TF), 27% intense trachomatous inflammation (TI), 17.7% trachomatous scarring (TS), 3.4% trachomatous trichiasis (TT) and 0.3% had corneal opacity (CO). The presence of a kitchen with chimney had a protective effect on TS (Adjusted Odds Ratio [AOR] = 0.82; 95% Confidence Interval [CI]: 0.65–0.96) and TT (AOR = 0.80; 95% CI: 0.53; 0.97). Active trachoma was more prevalent among children (AOR = 0.97; 95% CI: 0.96–0.97), illiterates (AOR = 1.38; 95% CI: 1.13–1.69) and those who infrequently wash their face (AOR = 1.35; 95% CI: 1.18–1.54). Conclusions: Trachoma is hyperendemic in the Tigray region. Mass chemotherapy, the expansion of primary eye care services, and promotion of a regular face washing habit are recommended. We recommend further investigations on the effect of domestic use of biomass energy on trachoma.

Optometry in a Hospital Setting

This study was designed to determine the extent to which optometry has been integrated within the hospital delivery system in New York State and to determine the types of services rendered by optometrists in governmental and non-governmental hospitals. A survey was developed and sent to all hospitals in the State to assess which hospitals provided eye care and whether optometrists were on staff. The number of optometrists affiliated with a hospital has increased from 27% in 1978 to 43% in 2003. Virtually all (90%) of city, county, and federal government hospitals used optometrists as compared to 32% of voluntary hospitals. Optometrists were found to provide a full range of medical ocular services including treatment. Given the cost savings of using optometrists, hospitals should consider integrating this profession into their primary eye care services.

Refractive error and visual impairment in African children in South Africa.

To assess the prevalence of refractive error and visual impairment in school-aged African children in South Africa. Random selection of geographically defined clusters was used to identify a sample of children 5 to 15 years of age in the Durban area. From January to August 2002, children in 35 clusters were enumerated through a door-to-door survey and examined in temporary facilities. The examination included visual acuity measurements, ocular motility evaluation, retinoscopy and autorefraction under cycloplegia, and examination of the anterior segment, media, and fundus. In nine clusters, children with reduced vision and a sample of those with normal vision underwent independent replicate examinations for quality assurance. A total of 5599 children living in 2712 households were enumerated, and 4890 (87.3%) were examined. The prevalence of uncorrected, presenting, and best-corrected visual acuity of 20/40 or worse in the better eye was 1.4%, 1.2%, and 0.32%, respectively. Refractive error was the cause in 63.6% of the 191 eyes with reduced vision, amblyopia in 7.3%, retinal disorders in 9.9%, corneal opacity in 3.7%, other causes in 3.1%, and unexplained causes in the remaining 12.0%. Exterior and anterior segment abnormalities were observed in 528 (10.8%) children, mainly corneal and conjunctival. Myopia (at least -0.50 D) in one or both eyes was present in 2.9% of children when measured with retinoscopy and in 4.0% measured with autorefraction. Beginning with an upward trend at age 14, myopia prevalence with autorefraction reached 9.6% at age 15. Myopia was also associated with increased parental education. Hyperopia (+2.00 D or more) in at least one eye was present in 1.8% of children when measured with retinoscopy and in 2.6% measured with autorefraction, with no significant predictors of hyperopia risk. The prevalence of reduced vision is low in school-age African children, most of it because of uncorrected refractive error. The high prevalence of corneal and other anterior segment abnormalities is a reflection of the inadequacy of primary eye care services in this area.

Childhood blindness in the context of VISION 2020--the right to sight.

The major causes of blindness in children vary widely from region to region, being largely determined by socioeconomic development, and the availability of primary health care and eye care services. In high-income countries, lesions of the optic nerve and higher visual pathways predominate as the cause of blindness, while corneal scarring from measles, vitamin A deficiency, the use of harmful traditional eye remedies, and ophthalmia neonatorum are the major causes in low-income countries. Retinopathy of prematurity is an important cause in middle-income countries. Other significant causes in all countries are cataract, congenital abnormalities, and hereditary retinal dystrophies. It is estimated that, in almost half of the children who are blind today, the underlying cause could have been prevented, or the eye condition treated to preserve vision or restore sight. The control of blindness in children is a priority within the World Health Organization's VISION 2020 programme. Strategies need to be region specific, based on activities to prevent blindness in the community--through measles immunization, health education, and control of vitamin A deficiency--and the provision of tertiary-level eye care facilities for conditions that require specialist management.

Primary eye care needs and services to Aboriginal and Torres Strait Islander populations across Queensland: a ‘users' perspective

The ocular health status of the Aboriginal and Torres Strait Islander (A&TSI) population is significantly poorer than that of the wider community. This study examined the primary eye care needs of, and services to, A&TSI people from an indigenous perspective. The findings reported here are based on questionnaire-based interviews of 292 A&TSI people from three urban and three rural communities in Queensland. The level of eye care services to A&TSI people failed to meet the perceived needs of most communities, this deficiency being greater in rural than urban communities. Limited physical accessibility of optometric services, cultural barriers and education were identified as the three main issues contributing to the low utilisation rate of currently available services by A&TSI people. These findings indicate unmet needs within A&TSI communities in Queensland, both for culturally appropriate and accessible primary eye care services and for education about eye health issues.

An Ophthalmic Survey of African Patients Presenting at Rural Eye Clinics in South Africa

The records of 10,254 people attending rural eye clinics in South Africa during 1984-85 were analyzed to determine the reasons for presentation. The main reasons for presentation were refractive error, conjunctivitis, and cataract. It is expected that population growth plus the increased vocational needs for the correction of refractive errors will result in an increased demand for optometric services in rural eye clinics. It is suggested that optometry has a major role to play in providing primary eye care services to the underserved populations of the South African homelands.

Training in community ophthalmology

It is a sad reflection on the provision of eye care worldwide, that of 30 million blind people in the world today, over 50% could be helped to see again by simple cataract surgery and a further 25% could have been prevented from going blind by basic promotive and preventive health care. Unfortunately the number of blind in the world is still increasing, largely because of an inadequacy of primary and secondary eye care services to people living in poor areas of the world. There is an urgent need to train health workers to provide these essential services.

Blindness in children and its management.

Blindness among children is a colossal problem, both in magnitude and its economic effects. Prevention of blindness is more gratifying than attempts to cure or rehabilitate those already blind. Under the Indian National Plan for the Control of Blindness launched in 1976, emphasis has been laid on imparting eye care education and delivery of primary eye care services as an integral part of general health services. Common causes of blindness in children, their prevention, treatment and rehabilitation are detailed.