Blindness and Low Vision – Causes

Dear teacher trainee, we will, in this unit learn about the different causes of
blindness and low vision. The many causes of blindness differ according to
the socioeconomic condition of a nation. In developed nations, the leading
causes of blindness include ocular complications of diabetes, macular
degeneration, and traumatic injuries. In third-world nations where blindness is
much more common and where about 85% of the world's blindness occurs,
principal causes include infections, cataracts, glaucoma, injury, and inability to
obtain any glasses.

Infectious causes in underdeveloped areas of the world include trachoma,

onchocerciasis or river blindness, and leprosy. The most common infectious
cause of blindness in developed nations is herpes simplex.

In spite of the progress made in surgical techniques in many countries during

the last ten years, cataract (47.9%) remains the leading cause of visual
impairment in all areas of the world, except for developed countries.

The blind population in India is estimated to rise to 15 million by the year

2020.
Cataract is the leading cause of blindness in India while refraction error and
glaucoma are the second and third leading causes of blindness respectively in
India.

In India since trachoma is limited, onchocerciasis is non-existent; glaucoma,

diabetic retinopathy and corneal diseases form priorities under India’s VISION
2020 action plan.
Some of the common causes of Visual Impairment are:

Prenatal Causes (Before birth)

 History of visual impairment in the family
 Consanguineous marriages (marriages between close relatives)
 Blood group complications or Rh incompatibility between the parents
 Infectious diseases or illnesses contracted by the mother during
pregnancy, specially syphilis or German measles (rubella), particularly
during the first three months of pregnancy
 Poor health of the pregnant mother
 Intake of antibiotics or any other drugs by the mother which are not
prescribed by a doctor
 Exposure to X-rays during pregnancy.
 Malnutrition, particularly Vitamin A deficiency.

Perinatal Causes (During birth)

 Premature delivery
 Low birth weight of the baby (birth weight less than 2.5 kg)
 Lack of oxygen to the infant during delivery
 Delivery using instruments (such as forceps) wrongly may cause damage
to parts of the brain responsible for seeing
Postnatal Causes (After birth)
 Infectious diseases (e.g. measles, syphilis, rubella, viral fever) contracted
 by the child during childhood
 Injury to the eye, such as a sharp object entering the eye, or a head injury
 Tumours in the eye
 Neglect of infection of the eye
 Vitamin A deficiency.

Thus we see that both hereditary (as indicated by history ·of visual impairment
in the family) and environmental factors (e.g. infectious diseases or injury) can
lead to visual impairment. Many of the environmental causes of visual
impairment are preventable. Proper care of the mother during pregnancy, the
presence of trained staff during delivery, adequate nutrition of the mother and
the child, especially intake of food rich in Vitamin A during childhood;
immunizing the child against preventable diseases and other such
precautionary measures can help in the prevention of visual impairment..
Many of the causes of visual impairment are preventable.

Cataracts
Let us now learn - What is a cataract?
A cataract is an eye disease in which the clear lens of the eye becomes
cloudy opaque, causing decrease in vision. Although the word cataract to
describe this condition has been part of the English language only since the
middle of the 16th century, the eye disease has been recognized and
surgically treated since ancient times.

The lens is a portion of the eye that is normally clear. It assists in focusing
rays of light entering the eye onto the retina, the light-sensitive tissue at the
back of the eye. In order to get a clear image onto the retina, the portions of
the eye in front of the retina, including the lens, must be clear and transparent.
Once light reaches the retina, the light initiates a chemical reaction within the
retina. The chemical reaction, in turn, initiates an electrical response which is
carried to the brain through the optic nerve. The brain then interprets what the
eye sees.

In a normal eye, light passes through the transparent lens to the retina. The
lens must be clear for the retina to receive a sharp image. If the lens is cloudy
from a cataract, the image striking the retina will be blurry and the vision will
be blurry. The extent of the visual disturbance is dependent upon the degree
of cloudiness of the lens.
Cataracts are very common in older people. By age 80, more than half of all
Americans either have some degree of cataract or have already undergone
cataract surgery in one or both eyes. By age 95, this percentage increases to
almost 100%. A cataract is not contagious and cannot spread from one eye to
the other or from person to person. They are neither painful nor make the eye
itchy or red.

Although vision can be restored in most people with cataracts, age-related

cataracts are still the most common cause of blindness in the world, primarily
because many third-world nations lack appropriate surgical services.

What are the different types of cataracts?

Cataracts can be classified by anatomical location within the lens, degree of
clouding of the lens, or by the cause of the cataract.

The lens of the human eye is shaped similar to candy. It has a front (anterior)
part and a back (posterior) part. The central portion of the lens is called the
lens nucleus, and the outer portion is called the lens capsule. Between the
inner nucleus and the outer capsule is a portion of the lens called the cortex.
Clouding of the lens can occur only in the nucleus, in which case the term
nuclear cataract or nuclear sclerosis is used. If the clouding occurs in the lens
cortex only, the cataract is termed a cortical cataract. If the loss of clarity of
the lens is primarily in the capsule, the term sub capsular cataract is used.
The location of the clouding can also be defined as being anterior or posterior,
central, or peripheral. Often the clouding of the lens may affect multiple
portions of the lens. The most common type of cataract that is related to age
is sometimes termed a senile cataract. This type of cataract primarily involves
the nucleus of the lens. Cataracts that develop in the posterior sub-capsular
area (in the rear region of the lens capsule) are more common in a younger
age group.

Any degree of loss of the normal transparency of the lens is called a cataract.
The more cloudy the, lens the more advanced the degree of cataract. A
cataract may be mild, moderate, or severe. It may be early or advanced. If the
lens is totally opaque it is termed a "mature" cataract. Any cataract that is not
opaque is therefore termed an "immature" cataract. Most mature cataracts are
white in colour.
What are causes of cataracts?
The lens is made of mostly water and protein. The protein is arranged in a
specific way that keeps the lens clear and allows light to pass through it to
focus a clear image onto the retinal surface. As we age, some of the protein
may clump together and start to cloud a small area of the lens. This is our
understanding of the cause of an age-related cataract. Over time, the cataract
may become more dense or cloud more of the lens, making it more difficult to
see through. A cataract is not a growth or tumor.

There are many causes of non-age-related cataracts or secondary cataracts.

Secondary cataracts are a result of similar changes to the protein of the lens,
also resulting in visual blurring or visual loss.

Blunt or penetrating injury to the eye may cause secondary cataracts, either
immediately after the injury or some weeks to years afterward. A cataract
following an injury may appear and then not increase in density (be stationary)
or be progressive. Eye surgery for other conditions can also cause cataracts.
Excessive exposure to ionizing radiation (X-ray), infrared radiation (as in glass
blowers), or ultraviolet radiation cause secondary cataracts.

Diabetes is associated with the development of secondary cataracts.

Inflammatory disease of the eye, such as iritis or uveitis, may cause or
accelerate the development of cataract in the involved eye.

There are many genetic illnesses that are associated with the development of
secondary cataracts. These include myotonic dystrophy, galactosemia,
homocystinuria, Wilson's disease and Down syndrome, plus many others.
Congenital infections with herpes simplex, rubella, toxoplasmosis, syphilis,
and cytomegalic inclusion disease may also result in cataracts.

There are many medications which, when taken over a long period of time,
can cause secondary cataracts. The most common of these are oral
corticosteroids, such as prednisone, which are used for a wide variety of
medical conditions.

The term "congenital cataract" is used when a baby is born with any clouding
of the lens. This may be present in one or both eyes, be stationary or be
progressive. Causes include genetic disorders or intrauterine developmental
disorders, both often associated with other physical abnormalities of the baby.
Atopic dermatitis, other diseases of the skin and mucous membranes,
hypothyroidism, and hyperparathyroidism are associated with the early
development of cataracts.

Patients who develop cataracts in both eyes at an early age often have family
members who have also developed cataracts prematurely, implying a genetic
cause, even in the absence of a recognized underlying disease.

What is glaucoma?
Glaucoma is a disease of the major nerve of vision, called the optic nerve.
The optic nerve receives light-generated nerve impulses from the retina and
transmits these to the brain, where we recognize those electrical signals as
vision. Glaucoma is characterized by a particular pattern of progressive
damage to the optic nerve that generally begins with a subtle loss of side
vision (peripheral vision). If glaucoma is not diagnosed and treated, it can
progress to loss of central vision and blindness.

Glaucoma is usually, but not always, associated with elevated pressure in the
eye (intraocular pressure). Generally, it is this elevated eye pressure that
leads to damage of the eye (optic) nerve. In some cases, glaucoma may
occur in the presence of normal eye pressure. This form of glaucoma is
believed to be caused by poor regulation of blood flow to the optic nerve.

How common is glaucoma?

Worldwide, glaucoma is the leading cause of irreversible blindness. In fact, as
many as 6 million individuals are blind in both eyes from this disease. In the
United States alone, according to one estimate, over 3 million people have
glaucoma. As many as half of the individuals with glaucoma, however, may
not know that they have the disease. The reason they are unaware is that
glaucoma initially causes no symptoms, and the subsequent loss of side
vision (peripheral vision) is usually not recognized.

What causes glaucoma?

Elevated pressure in the eye is the main factor leading to glaucomatous
damage to the eye (optic) nerve. The optic nerve, which is located in back of
the eye, is the main visual nerve for the eye. This nerve transmits the images
we see back to the brain for interpretation. The eye is firm and round, like a
basketball. Its tone and shape are maintained by a pressure within the eye
(the intraocular pressure), which normally ranges between 8 mm and 22 mm
(millimeters) of mercury. When the pressure is too low, the eye becomes
softer, while an elevated pressure causes the eye to become harder. The
optic nerve is the most susceptible part of the eye to high pressure because
the delicate fibers in this nerve are easily damaged.

The front of the eye is filled with a clear fluid called the aqueous humor, which
provides nourishment to the structures in the front of the eye. This fluid is
produced constantly by the ciliary body, which surrounds the lens f the eye.
The aqueous humor then flows through the pupil and leaves the eye through
tiny channels called the trabecular meshwork. These channels are located at
what is called the drainage angle of the eye. This angle is where the clear
cornea, which covers the front of the eye, attaches to the base (root or
periphery) of the iris, which is the coloured part of the eye. The cornea covers
the iris and the pupil, which are in front of the lens. The pupil is the small,
round, black-appearing opening in the center of the iris. Light passes through
the pupil, on through the lens, and to the retina at the back of the eye. Please
see the figure, which is a diagram that shows the drainage angle of the eye.
This diagram of the front part of the eye is in cross section to show the
filtering, or drainage, angle. This angle is between the cornea and the iris,
which join each other right where the drainage channels (trabecular
meshwork) are located. The arrow shows the flow of the aqueous fluid from
the ciliary body, through the pupil, and into the drainage channels. This figure
is recreated from Understanding and Treating Glaucoma, a human anatomy
board book by Tim Peters and Company Inc., Gladstone N.J.

In most people, the drainage angles are wide open, although in some
individuals, they can be narrow. For example, the usual angle is about 45
degrees, whereas a narrow angle is about 25 degrees or less. After exiting
through the trabecular meshwork in the drainage angle, the aqueous fluid
then drains into tiny blood vessels (capillaries) into the main bloodstream. The
aqueous humor should not be confused with tears, which are produced by a
gland outside of the eyeball itself.

This process of producing and removing the fluid from the eye is similar to
that of a sink with the faucet always turned on, producing and draining the
water. If the sink's drain becomes clogged, the water may overflow. If this sink
were a closed system, as is the eye, and unable to overflow, the pressure in
the sink would rise. Likewise, if the eye's trabecular meshwork becomes
clogged or blocked, the intraocular pressure may become elevated. Also, if
the sink's faucet is on too high, the water may overflow. Again, if this sink
were a closed system, the pressure within the sink would increase. Likewise,
if too much fluid is being produced within the eye, the intraocular pressure
may become too high. In either event, since the eye is a closed system, if it
cannot remove the increased fluid, the pressure builds up and optic-nerve
damage may result.

Diabetic retinopathy
Diabetic retinopathy is damage to the retina caused by complications of
diabetes, which can eventually lead to blindness. It is an ocular manifestation
of diabetes, a systemic disease, which affects up to 80 percent of all patients
who have had diabetes for 10 years or more.[3] Despite these intimidating
statistics, research indicates that at least 90% of these new cases could be
reduced if there was proper and vigilant treatment and monitoring of the eyes.
The longer a person has diabetes, the higher his or her chances of developing
diabetic retinopathy.
Early disease may not cause symptoms. As the disease progresses, it enters
its advanced, or proliferative, stage. Fragile, new blood vessels grow along
the retina and in the clear, gel-like vitreous that fills the inside of the eye.
Without timely treatment, these new blood vessels can bleed, cloud vision,
and destroy the retina. Everyone with type 1 or type 2 diabetes is at risk for
diabetic retinopathy.

Diabetic retinopathy often has no early warning signs. Even macular edema,
which may cause vision loss more rapidly, may not have any warning signs
for some time. In general, however, a person with macular edema is likely to
have blurred vision, making it hard to do things like read or drive. In some
cases, the vision will get better or worse during the day.

As new blood vessels form at the back of the eye as a part of proliferative
diabetic retinopathy (PDR), they can bleed (vitreous hemorrhage) and blur
vision. The first time this happens, it may not be very severe. In most cases, it
will leave just a few specks of blood, or spots, floating in a person's visual
field, though the spots often go away after a few hours.

These spots are often followed within a few days or weeks by a much greater
leakage of blood, which blurs vision. In extreme cases, a person will only be
able to tell light from dark in that eye. It may take the blood anywhere from a
few days to months or even years to clear from the inside of the eye, and in
some cases the blood will not clear. These types of large hemorrhages tend
to happen more than once, often during sleep.

Swelling in the portion of the retina that is most sensitive to light makes it hard
for a patient to do things like read and drive. As new blood vessels form at the
back of the eye, they can bleed and further blur vision. Large haemorrhages
tend to happen more than once, often during sleep. There are no early
warning signs. It is strongly recommended that all diabetics have eye
examinations at least once (ideally twice) a year.

Refraction error
A refractive error, or refraction error, is an error in the focusing of light by the
eye and a frequent reason for reduced visual acuity.

A refractive error is a very common eye disorder. It occurs when the eye
cannot clearly focus the images from the outside world. The result of
refractive errors is blurred vision, which is sometimes so severe that it causes
visual impairment.

The three most common refractive errors are:

1. Myopia or nearsightedness: difficulty in seeing distant objects clearly;
Myopia occurs when the cornea is too curved or when the eyeball is too long.
This causes the light to focus in front of the retina and as a result the image
formed on the back of the eye is not as sharp as it should be.

2. Hyperopia or farsightedness: difficulty in seeing close objects clearly;

Hyperopia is usually caused by the eyeball being smaller than normal. This
means that the light cannot focus on the retina - it would focus “behind” the
back of the eye. When the eye is young enough and has strength to increase
it focusing power good near vision is possible but will generate eyestrain.
When this is not possible, near vision will become blurry.
3. Astigmatism: distorted vision resulting from an irregularly curved cornea,
the clear covering of the eyeball. Astigmatism is the result of the irregular
curvature of the cornea or of a more oval shaped eyeball.

A fourth condition is presbyopia, which leads to difficulty in reading or seeing

at arm's length. It differs from the other disorders in that it is linked to ageing
and occurs almost universally.

Refractive errors cannot be prevented, but they can be diagnosed by an eye

examination and treated with corrective glasses, contact lenses or refractive
surgery.

WHO estimates that 153 million people worldwide live with visual impairment
due to uncorrected refractive errors. This figure does not include the people
living with uncorrected presbyopia, which is likely to be quite significant,
according to some early evidence.

WHO, its Member States and partners are working to find ways to provide
local, affordable corrective optical services to people in need, especially in
poor areas with limited eye care services.

Conclusion
When you think about it, the very act of actually seeing the world around us is
an astonishing thing. It relies on the interaction between the brain and the
eyeball, two extraordinarily complex organs, so it's hardly surprising that there
are so many ways in which we can suffer sight loss or reduction.

The National Programme for Control of Blindness (NPCB) was launched in

1976 as a 100% centrally sponsored scheme with the goal of reducing the
prevalence of blindness from 1.4% to 0.3%. According to a survey in 2001-02,
the prevalence of blindness was estimated at 1.1%. The target for the 10th
Plan was to reduce this to 0.8% by 2007. A survey done in 2006-07 estimated
the prevalence of blindness at 1%.

The main causes of blindness in India are as follows: - Cataract (62.60%)

Refractive Error (19.70%) Corneal Blindness (0.90%), Glaucoma (5.80%),
Surgical Complications (1.20%) Posterior Capsular Opacification (0.90%)
Posterior Segment Disorder (4.70%) and Others (4.19%). The estimated
national prevalence of childhood blindness /low vision is 0.80 per thousand.