You are on page 1of 76

Public health ophthalmology

Objective
definition of impairment, disable and
handicap
register of blindness
epidemiology of blindness
prevention of blindness
principle of visual rehabilitation

Public health ophthalmology


Impairment
function loss of organ system

Disable
loss of ability of the person

Handicap
loss of socioeconomic well being of the person

Public health ophthalmology


A 43-year-old man suffered from eye trauma. His
vision is CF in both eyes. He can go to work as a
lecturer in one university but he can not drive a
car. He lives with his wife and has 1 son. His
family accept for his condition and are happy.
What is the impairment?
What is his disable?
Does this man a handicap?

Public health ophthalmology


A 54-year-old man suffered from POAG. He has
poor visual acuity of 20/200 and very constricted
visual field. He has experienced multiple car
accident. He can difficulty reading and cannot
work as a architect any more. He was divorced
and live alone with some help from his mother.
What is the impairment?
What are his disable?
Does this man a handicap?

Public health ophthalmology


A 18-year-old man is not accepted for a medical
student application because of his color blindness.
His VA are 20/20 in both eyes. VF are within
normal limited. He failed in Ishihara Test.

What is the impairment?


What are his disable?
Does this man a handicap?

Public health ophthalmology


Visual impairment
bilateral condition
presenting visual acuity
visual field
degree of impairment (level)

Visual impairment
level
Low vision

blindness

Presenting
VA

VF

<6/18 (20/60) 10-30 degree


-6/60(20/200)

<6/60(20/200)
-3/60(10(200)

<3/60(10/200) 5-<10 degree


-1/60(CF3 Ft)

<1/60(CF 3Ft)
-PL

NLP

<5 degree

Public health ophthalmology


A 54-year-old man suffered from POAG. He has
poor visual acuity of 20/200 and very constricted
visual field(<5 degree) in both eyes.
Is this man classified as low vision or blindness?
Which level of visual impairment will you classify
this man?

Register of blindness

Public health ophthalmology


33 year old man suffered from cataract. His vision
are OD:20/200 improved to 20/40 with pinhole
and OS:CF 2Ft. VF are within normal limited.
Is this man classified as low vision or not?
Will you register him as a visual impairment(low
vision or blindness)? And why?

Register of blindness
any level of visual impairment
Irreversible
clearly apparent
no eye(post enucleation/exenteration)
phthisis bulbi/atrophic bulbi
examination
phthisis bulbi
not reactive pupil
optic atrophy/full cupping
extensive retinal scar

Public health ophthalmology


A 24-year-old man want to be blindness registered.
VA are OU:CF 1 Ft. VF are constricted in both eyes.

Retinitis Pigmentosa

What is the proper management?

Example
A 6-year-old girl suffered from glaucoma.
VA are 20/200 . VF are very constricted.
Refer for register blindness & education
A 31-year-old girl suffered from glaucoma.
VA are 20/200 . VF are very constricted.
Refer for register blindness, medical rehabilitation
(orientation & motility training) and occupational
training(Thai massage, agriculture, etc.)

Public health ophthalmology


Global data on visual impairments 2010
Total number
Visual impairment 285 m
low vision 246m
blind 39m
or prevalent of
Visual impairment 4.24%
low vision 3.65%
blind 0.58%

Epidemiology of blindness
Prevalence of blind, low vision and visual impair /thousand
60
in region
50

40
30
20

blind/thousand

10

low
vision/thousand
visual
impair/thousand

0
AFR

AMR

EMR

EUR

SEAR

WPR

india

china

Public health ophthalmology


Blind/visual impairment ratio
Africa = 0.224
America = 0.121
East Mediterranean = 0.209
Europe = 0.096
Southeast Asia = 0.133
West Pacific = 0.159
India = 0.129
China = 0.109

Epidemiology of visual impairment


age

Population
(million)

Blind
(percent)

Low vision
(percent)

Visual impair

0-14

1848.5

0.065

0.948

1.025

15-49

3548.2

0.163

2.099

2.27

50or>

1340.8

2.399

11.489

13.888

All ages

6737.5

0.584

3.65

4.24

(percent)

Epidemiology of visual impairment


global cause of visual
impairment

global cause of blindness

RE

refractive error

cataract

cataract

undetermine

undetermine

glaucoma

glaucoma

childhood

childhood

AMD

AMD

DR

DR

trachoma

trachoma

CO

CO

Thailand
1.2

1.14

What happen?

0.8

0.58

0.6

0.59

0.4

0.31
0.2
0

1983

1987

1994

2006

prevalent of
blindness(percent)
prevalent of blinding
cataract(percent)

Population growth of thailand

Epidemiology of blindness
cause of blindness in Thailand

RE
cataract

undetermine
glaucoma
childhood
AMD

DR
trachoma
CO

Very similar

Thailand blindness situation


Unknown incidence

Incidence of 1:1,000

Other cause of blindness


about 210,000

Other treatment
& rehabilitation
Estimate Thai population of 70m, we
will reduce prevalent of blindness to
0.3-0.4% in 3-4 years

Blinding Cataract
about 210,000

Cataract surgical rate


>2:1,000
>140,000 cataract surgery/year
>100 cataract surgery/year/Ophthalmologist
But must be 100% blinding cataract and
Just only one eye operation

Thailand blindness situation


What is the trend of visual impairment in
Thailand?
What should be the cause of blindness in Thailand
in the next 10 years?

Prevalence of blindness in New Zealand 2009

Impact of visual impairment


Economic

Quality of life

Prevention of blindness
Primary prevention
prevent disease occurring
Host, Agent &Environment control
Secondary prevention
prevent complication by early
Dx and early Rx
screening
Tertiary prevention
prevent disability
treatment and rehabilitation

Prevention of blindness
Which cause of blindness is the major target in
prevention of blindness?
What is your role in prevention of blindness?
What can we do in our country?

Prevention of blindness
Cataract
secondary/tertiary prevention
cataract surgery is cost-effective procedure
low rate of complication BUT may be severe

Cataract surgery program


Routine
Less patients
Long waiting time
Regular
Less complication

Campaign
more patients
short waiting time
occasionally
more complication

Campaign may be use during the early stage in


some area with large backlog but routine is better
in the long run.

Cataract surgery program


Policy setting blinding cataract
decrease waiting time <..months
incentive
free of charge if indicate

How do you determine the criteria for cataract


surgery?

DR screening
Screening tool
Direct ophthalmoscope
Indirect ophthalmoscope
Slit lamp biomicroscopic examination
Fundus camera

?
?
/
/

DR screening
Who will take the responsibility of
fundus camera interpretation?

What is the criteria for referring to


Ophthalmologist?
How do we do ?

Amblyopia screening
Preschool age 4-6 year old
effective treatment

reliability

Screening tool
VA chart: E-game, Randolts broken ring, etc.
Alignment/Stereopsis

Amblyopia screening

Amblyopia screening
Who should be involved in Amblyopia screening?
How do you do in visual impaired children?
Is this program effective in prevention of
blindness?
Why does it ?

ROP screening
prematurity / oxygen therapy
high risk group
BW < 1500 gm GA < 32 week oxygen Rx > 4 hour

Fundus examination
criteria for screening
criteria for treatment

ROP screening
What is the cause of blindness in ROP?
How will we do for detection of its complication?
Does it cost-effective procedure?

Glaucoma screening
2 of 3 criteria
increase ocular tension
visual field defect
optic nerve damage

POAG is the main target


asymptomatic
high prevalence

Risk of POAG
aging > 40
family history

Glaucoma screening
What is the proper strategy
for disease screening?
Which test will you use for
screening?

If you has good idea about it,


please do it and you may win
a big prize.

Prophylactic for Ophthalmia


neonatorum
Cause
GC, chlamydia, other bacteria
virus, and chemical
Prophylacis
Credes solution ( 2% AgNO3)
but severe reaction
1% AgNO3
GC is cause in the most
severe cases, and is the
main target to treated.

Prophylactic for Ophthalmia


neonatorum
1% AgNO3 may cause chemical conjunctivitis?

What is the alternative prophylacis of Ophthalmia


neonatorum?
What is the other strategy for prevention of this
condition?

Pterygium/Pinguecular prevention
Exposure to UV
Tropical area, farmer & fisherman

Sunglasses is the most effective


prevention.
Bad image of sunglasses
How will you educate of wearing
sunglasses?

Eye trauma prevention

Eye trauma prevention

Eye trauma prevention in factory


Environmental health
5S explanation
Ergonomy
Promotion of immunity
protective device
healthy labor
Health policy
early treatment
maintaining of health

Eye protective instrument

Eye Traffic injury prevention

Safety standard

Eye Traffic injury prevention


Safe street

safe driver

Driving Licence

BUT

Visual rehabilitation

Agent

Disorder

Impairment

Disable

Handicap

anatomical

functional

skill/ability

social &
economic

Primary
prevention

Secondary
prevention

Tertiary
prevention

(Treatment)

Medical
rehabilitation

Doctor role

Social & Education


rehabilitation

Visual rehabilitation

Quality of life dimension

Visual rehabilitation

Public health ophthalmology

Public health ophthalmology

Sighted guide

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Living with the blind

High contrast & simple

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology

Public health ophthalmology