You are on page 1of 47

Rehan Shareef Butt

Roll number 21
Introduction strategies

Global and Issues and

regional challenges

Global Proposed
strategies strategies








Raised IOP.
Field of vision defects.
Family history and genetics.
Central corneal thickness.
Myopia ( near sightedness).
Socio economic deprivation.
Visual Impairment due to
Glaucoma: Ages 45 and Over
Ages 45 and over



Less than high

High school
At least some
With diabetes
0 10 20 30 40 50
Rate per 1,000 persons
Note: Data are age adjusted to the 2000 standard population. American Indian includes Alaska Native. Black and white
exclude persons of Hispanic origin. Persons of Hispanic origin may be any race. I is 95% confidence interval. *Data are
statistically unreliable.
Globally, around 45 million people are blind
and a further 124 million are affected by
low vision.
Around 90% of worlds blind live in
developing countries and many people do
not receive treatment.
More than 75% of world’s blindness is
preventable or treatable.
WHO has estimated that without major
intervention, the number of people who are
blind will double to approx 76million by
Glaucoma is the second leading cause of
blindness globally as well as in most of the
The number of persons estimated to be
blind as a result of glaucoma is 4.5 million
accounting for slightly more than 12% of all
Although the prevalence of glaucoma is
12% but the alarming thing is that, this
prevalence is gradually increasing by time.
A sharp rise in aging population will
probably cause a 30% increase in the
number of pts with POAG by 2020 with an
estimate of 58.6 million affected and 5.9
million bilaterally blind.
According to Pakistan National Blindness
and Visual Impairment Survey, the age and
gender standardized prevalence of
blindness among Pakistan adults (30yrs or
older) was 2.7%.
The estimated number of blind individuals
of all ages in Pakistan in 2003 was 1.25
Using population projection for whole
population of Pakistan, the number of blind
people will increase to approx 2.4million by
Previous studies in districts of NWFP found
women to be more likely to be blind or
visually impaired than men.
Another study in Northern Punjab found
nearly double the prevalence of
blindness in women than in men.
The age adjusted odds of blindness in
women is 43% higher than in men.
Underutilization of eye care services and
barriers specific to women are the
A significantly high prevalence of
blindness is found in districts with a
higher deprivation index.
According to Pakistan National
Blindness Survey Glaucoma is the 3rd
leading cause of blindness in Pakistan.
Vision 2020 The Right To Sight:
Launched in 1999 as a partnership
between WHO and IAPB.
The goal of Vision 2020 is to eliminate
avoidable blindness by the year 2020.
Strategy includes cost effective disease
control interventions, HR management and
infrastructure development.
Vision 2020 workshops:
Started in 1995 with 6 regional partners
including Pakistan.
Participants include eye health
professionals and health service planners.
World sight day:
Annual day of awareness to focus global attention
on blindness and visual impairment.
World glaucoma Association:
Independent, ethical and impartial global
organization for glaucoma science and care.
Mission is to optimize the quality of glaucoma
science and care through communication and
cooperation among glaucoma societies and
World glaucoma congress is the only biennial
glaucoma meeting conducted by WGA.
The glaucoma foundation:
The mission of TGF is to find ground breaking
research and to educate the public about this
disease and importance of early detection to
prevent blindness.
World glaucoma day:
Celebrated once a year to create awareness
about glaucoma in general public.
Activities include media coverage, public
educational events and free screening events .
National program for prevention and
control of blindness:
This program is in line with Vision 2020.
Core objectives:
Prevention of blindness in 2 million people.
Restoration of vision in 2 million people.
Strategic targets:
Establishment of 7 centers of excellence in
Up gradation of 17 TTH eye units.
Up gradation of 63 DHQ eye units.
Up gradation of 147 THQ eye units.
Training of 50,000 LHW,s in prim eye care.
Targets 2005-06 2006-07 2007-08 Progress

COE 7 1 2 4 100%
TTH eye 19 0 3 10 68%
DHQ eye 63 22 8 15 71%
THQ eye 147 0 0 0 Nil
There is a lot of work done in prim and
sec eye health sector but prim eye
care sector is highly neglected.
The main reason for not up grading
THQ is non availability of trained
human resource at these hospitals.
Federal Punjab Sindh NWFP Baluchista
capital n
Total cost 21.77M 182.42M 91.29M 91.29M 28.39M
incurred in

Up Up Up Up Up Up
gradation gradation gradation gradation gradation gradation
of FGSH as of Nishtar of Civil of of Helper
TTH Hospital Hospital Hayatabad Eye
Multan as KCH as Medical Hospital as
as COE
Up Up Up No TTH up
gradation gradation gradation graded
of 5 TTH of 2 TTH of 2 TTH
Up Up Up No DHQ up
gradation gradation gradation graded
of 7 DHQ of 2 DHQ of 3 DHQ
Training of LHW,s in prim eye care:
This program plans to provide training to 50,000 LHW,s
in primary eye care all over Pakistan by 2010.
A total of 5000 LHW,s have been given training
sessions in primary eye care and another 25000 were
trained during financial year 2008-09.
The main function of LHW,s will be to refer those
patients who need immediate attention, to up graded
eye hospitals.
Pakistan Institute of community ophthalmology
Punjab Institute of Preventive Ophthalmology
International NGO,s include Fred Hollows
Foundation, Sight savers International.
Pak Australia District Eye Care Program focuses
heavily on HR and infrastructure development,
the provision of equipment and community
At primary level it aims to enhance the capacity
of health care workers in RHC,s Government
dispensaries and BHU,s to treat eye diseases
including glaucoma and to educate the
community members about eye care.
Pakistan Glaucoma Association:
The objective of this association is to promote the
awareness, education and research and patient care
particularly with regard to current and advanced concepts
in glaucoma care both in medical profession as well as in
general population.
The activities are aimed at pooling the HR to build
capacity on a national level in appropriate treatment of
Recently a seminar was conducted on Prevention of
Glaucoma organized by Jung Group in collaboration with
It was said that prevention and detection at early stage
with effective diagnosis and treatment could prevent up
to 80% cases of blindness due to glaucoma.
Dearth of trained HR:
2711 additional posts in eye care are required to be
created at the up graded hospitals all over Pakistan.
Not a single refractionist has been deputed at any of
the up graded DHQ.
Most of DHQ,s have only one trained ophthalmic
technician and in the absence of allied staff , the eye
specialist has no support.
Except Punjab, no post has been created yet.
Deficient physical infrastructure.
Non availability of medicines
Deficient data collection and transmission
Baluchistan issue:
No eye specialist is available at any of the 6
procured DHQ,s of Baluchistan leading to non
utilization of equipment worth millions of
rupees and depriving the local population of
free eye care facilities.
No progress has yet been made despite
different meetings with provincial government.
No resources for media campaign.
In appropriate vehicles for monitoring and
Low motivation of personnels.
Poor surveillance system
Identification of aims and objectives:
Aim: Eradication of blindness due to
glaucoma in Pakistan by 2020.
Objectives :
To make prim eye care accessible to everyone.
Cadre of trained personnels to be created for
eye care.
To achieve glaucoma prevalence rate for
identifiable sub groups below 1%.
Increasing the number of trained eye
Up gradation of BHU/THQ eye units.
Raising the awareness of the general public as
well as health professionals regarding
Modes of financing:
Expanding tax based revenues
Standardization of fee structures.
Allocation of donor funds according to needs.
Expansion of employees’ social security schemes.
Development of social protection programs.
Private sector reforms:
Updating the knowledge and skills of private sector
eye health care providers.
Develop criteria for regular inspection of private
eye care facilities.
Conducting research for evidence on the
functioning of private eye health care sector.
Using the National Health policy Forum to build up
relationship with Federal Planning division to
convince MOH about taking actions and making
policies about blindness due to glaucoma.
Urging Ministry of Finance to increase the funds for
Blindness Control Program with specific allocation
for glaucoma control and prevention activities.
Involving the provincial secretaries of health in the
creation of provincial committees for prevention of
blindness due to glaucoma. As a result it will be
possible to coordinate, plan and make decisions
about the program at provincial levels.
Involving the district administrators in planning of eye
care programs.
Building the leadership and management skills of the
health officials and district ophthalmologists.
Specific training of mid level eye care personnels.
Recruitment of ophthalmologists and allied staff at the
vacant posts specifically in the rural areas.
Assigning an expert group which should design public
health approaches for control of glaucoma associated
blindness in context of Vision 2020.
Ensure that training curricula of ophthalmologists
adequately address glaucoma, including the skills
needed for diagnosis and treatment.
Training centers should be adequately equipped to
provide essential services for glaucoma patients.
Identifying the opportunities for diagnosing
glaucoma for example at the time of refraction
testing; before or after cataract surgery.
Making glaucoma screening, a part of regular eye
checks particularly for persons at risk( with a
positive family history, more than 40 years of age).
Increasing the compliance with the use of eye
drops through health education and counseling.
Arranging free glaucoma camps with free eye
check ups of all the people with focus or rural and
poor areas.
Public awareness campaign
• Media coverage through newspaper articles and
editorials, radio station coverage, TV channel
coverage. This can be done by telecasting at least
one program about glaucoma awareness monthly.
• Organizing open door eye care days at institutions.
• Distribution of IEC material showing the key
messages about glaucoma in general population.
• Organizing patient educational conference at
institutions or public venues.
• Organizing free screening days at institutions and
public venues.
• Celebration of glaucoma days in whole country with
increased awareness activities in rural areas.
HR development:
Training lady health workers in primary eye care or
at least making them aware of the sight threatening
conditions such as glaucoma.
Mid level eye care personnels should also be given
priority training so that they can early diagnose it
and at least refer to a secondary eye care facility.
Providing performance based incentives to the eye
care staff.
Training of new ophthalmologists and
glaucomatologists and deputing them to vacant
Providing more incentives and allowances to the
ophthalmologists who agree to work in
socioeconomically deprived areas.
Increasing the number of training centers for eye
health care staff.
Place the personnels trained in management at
tertiary and secondary care centers.
Train full time managers in larger courses as
Appointing biomedical engineers for maintenance
and repair of eye care equipment.
Infra structure development:
Up gradation of DHQ and THQ eye units with provision
of indoor facilities.
Identify the poorly served areas and engage with
partners to secure the resources for infra structure
development in those areas.
Support the operational research on increasing the
productivity of available infra structure.
Improvement of access to infra structure by providing
transport facility for ophthalmic teams and patients.
Establishment of separate glaucoma clinics at
secondary and tertiary level facilities.
Provision of high quality affordable equipment to
practitioners, hospitals and clinics.
Provide appropriate donated equipment to facilities
that cannot afford to purchase.
The monitoring and evaluation should be the
responsibility of Project Management Unit
A separate committee should be made for this
specific task which should submit its evaluation
report to the project managers every 6 months.
The best way for monitoring and evaluation is
through specific indicators which are devised after
keeping in view the objectives of the program.
Monitoring and evaluation frame work
BCC indicators:
Proportion of people who have knowledge about
glaucoma and its complications.
Number of glaucoma awareness programs telecasted in
last 6 months.
Number of patient educational conferences held in last
6 months.
Number of free screening days organized in last 6
HR Indicators:
Number of eye care personnels (including
ophthalmologists and mid level eye care staff) per
100,000 population.
Proportion of residency programs that have integrated
a community ophthalmology module into their
Proportion of training curricula of eye health
care staff which adequately address glaucoma
diagnosis and management.
Number of eye care personnels trained for
glaucoma diagnosis and management (short
and long courses)
Ratio of ophthalmic medical assistants,
officers and nurses to ophthalmologists.
Proportion of sec and tertiary level centers
with trained ophthalmologists.
Number of vacant ophthalmologist and allied
staff posts filled.
Number of LHW,s trained in primary eye care.
Proportion of eye health care staff satisfied
with their job.
Indicators for infra structure:
Number of primary, sec and tertiary eye care
Number of DHQ,s and THQ,s eye units up
Number of district eye units with adequate
diagnosis and treatment facilities.
Major indicators:
Proportion of different types of glaucoma in
districts and provinces.
Proportion of people with visual impairment
in districts and provinces.
Proportion of people who are blind in
districts and provinces.
The key to success is early and timely
diagnosis accompanied with regular follow up
of the patients with glaucoma. This can only
be achieved by creating awareness about this
disease in target groups and changing their
behavior through effective BCC strategies
accompanied with the provision of high quality
primary eye care at the tehsil and district
level. This is the only way by which the Vision
2020 goal of reducing the blindness and visual
impairment due to glaucoma can be achieved
at the global as well as the national levels.
1) - Alguire P (1990), Walker H.K, Hall W.D, Hurst J.W, Clinical Methods: The history,
physical and lab examination(3rd edition), London: Butterworth. ISBN 0-409.
2) - NEI ( National Eye Institute, US Health Department)
3) – American Journal Of Epidemiology: 1991 Vol 134, Number 10, p: 1102-1110.
4) – Archives of Ophthalmology 1998; 116: 1640-1645, 1994; 112: 69-73, Survey of
Ophthalmology 2002; 47: 547-61.
5) – HMG Oxford Journals Feb 5, 2004, Genetic Dissection of Myocilin Glaucoma:
Gordon Gong, Omofolasade Kosoko et al.
6) – Physiological Basis Of Ageing and Geriatrics by Paola S Timrias
7) – Mitchell Ophthalmology 1999; 106: 2010-15
8) – Ellis.Br Journal Of Ophthalmology 2000; 84: 1218-24, Dielemens Ophthalmology
1995; 102: 54-60
9) – Bonomi Ophthalmology 2000; 107: 1287-93, Tielsch Arch Ophthalmology 1995;
113: 16-21
10) – Deprivation and late presentation of Glaucoma: Case Control Study, Scott
Foster, Catey Bunce, Eric Brunner.
11) – Blindness and visual impairment: Global Facts, Vision 2020
12) – State of The worlds Sight, Vision 2020; Executive Summary and full report
p27-30; Quigley HA, Broman AT; The number of people with glaucoma world wide in
2010 and 2020; British Journal of Ophthalmology 2006; 90: 262-267