Last fall, the World Health Organization published the first World Report on Vision with the goal of providing countries worldwide with a systematic approach to improving vision for as mafny people as possible. It is an appeal to governments, international organizations, donors, public and private sector to provide a long-term sustainable framework for “people-centered eyecare” for everyone. The goal is to “help countries prevent eye conditions and vision impairment more effectively and provide quality eyecare services according to the needs of their populations” (WHO World Report on Vision vi).
More than 1 billion people are living with vision impairment from preventable or treatable conditions like uncorrected refractive error, cataracts and glaucoma. 65 million people are blind or visually impaired due to cataracts and over 800 million struggle with daily activities due to uncorrected refractive error.
This report is based on many surveys and populations-based research regarding met and unmet eyecare needs worldwide. Therefore, the more data in these areas available, the more accurate global need can be calculated and progress monitored. All future planning recommended for nations is based on the need for complete data to track progress.
There have been several global eyecare initiatives gearing up to an important year for vision, 2020. Some key goals set over the past 2 decades include:
- Vision 2020 Initiative: started in 1999, focused on main causes of avoidable blindness that had cost-effective interventions available such as: cataract, trachoma, onchocerciasis (river blindness) and childhood blindness
- In 2006, Vision2020 Initiative added to their goals the elimination of vision impairment, primarily uncorrected refractive error
- Universal Eye Health Action Plan: started in 2014: goal to reduce avoidable visual impairment by 25% by 2019 from baseline in 2010
Many countries have set goals, measured vision impairment and blindness from a variety of causes and reduced these numbers. However, globally numbers of vision impairment are still climbing due to the aging population.
The burden of vision impairment is not equally distributed worldwide. It is greater for those living in rural areas, ethnic minorities, low income status, homeless, refugee, elderly, disabled and women (in some countries). Low and middle income regions have unmet needs of distance vision impairment that are four times greater than in high income regions.
There are many barriers to reaching all those in need of eyecare services. They include: physical barriers, such as far distance to medical facility; financial burden to individual and/or country; hospitals/clinics lacking appropriate ophthalmic equipment; sufficient personnel as well as the disbelief by some that treatment will have proposed outcome. Lack of access means suffering with vision impairment, worsening of disease and often utilizing local remedies which may worsen the condition.
Vision impairment poses a financial burden globally in loss of productivity as well as costs of disease treatment. As an example, “annual global costs of productivity losses associated with vision impairment from uncorrected myopia and presbyopia alone were estimated to be US$ 244 billion and US$ 25.4 billion, respectively” (WHO World Report p. 16). It is estimated that to address the backlog of disease from vision impairment would currently cost $14.3 billion to address the 1 billion people suffering from vision impairment and blindness due to uncorrected refractive error and cataracts alone.
These numbers are staggering. How do we begin to address the needs of so many people worldwide suffering unnecessarily from vision impairment? WHO insists eyecare services must be a part of each nation’s universal health coverage. Additionally, public health campaigns regarding the nature of eye health problems must become more widespread so that people can accept preventive strategies, treatment and rehabilitation services as they become available. Over the past several decades, many countries have used this strategy to reduce the risk of trachoma related vision impairment. As a result 8 countries—Cambodia, Ghana, the Islamic Republic of Iran, Lao People’s Democratic Republic, Mexico, Morocco, Nepal and Oman—have now eliminated trachoma as a public health problem (WHO World Vision Report 54).
The use of telehealth has been particularly useful for those living in rural and remote areas of many countries. Mobile-based software applications can allow for vision assessment as well as disease detection in many scenarios where patients live too far from clinics and may not know that their vision could be improved. This area shows huge potential for the future to enhance access and improve quality of health care in a variety of settings.
In Australia, Lion’s Outback Vision, part of Lion’s Eye Institute, since 2011 has been using telehealth eye exams with ophthalmologists and optometrists. Since this time, the non-attendance rate at outreach service visits dropped from 50% to 3%. It also reduced duplication of services.
In 2003, England began a program to screen all individuals ages 12 and over with diabetes for diabetic retinopathy. Mailed reminders invite all individuals with diabetes for annual screening. Screening consists of visual acuity, dilation and 2-field retinal photos which are sent via telemedicine to trained non-physician screening technicians to grade level of retinopathy. Since 2008, the program has reached >80% of the population screened for diabetic retinopathy. After 7 years of utilizing this program, the blindness registry in England revealed that diabetic retinopathy was no longer the leading cause of blindness in the working age population. (WHO World Report on Vision 56) By contrast, in the United States, diabetic retinopathy remains the leading cause of vision impairment in working age adults ages 20-74 according to the CDC.
The future of eyecare
Eyecare is needed worldwide to address the growing number of ocular conditions, both those that affect vision and those that don’t. Some conditions, like cataracts, can be treated with a one time surgery, however other conditions, like glaucoma, diabetic retinopathy or retinopathy of prematurity, require ongoing care. Additionally, with the number of people with myopia increasing, especially in populations with rapid economic growth, like in East Asia, complications from high myopia are going to become more prevalent. It is expected that the number of children and adolescents with myopia will increase by 200 million between the years 2000 and 2050 (79). The growing number of conditions leading to vision impairment and blindness will also increase the need for low vision/rehabilitation services worldwide.
In order to improve vision worldwide, accurate records of vision problems are needed. Data estimates/surveys fall short in that they are difficult to carry out and require resources. Additionally, not all countries have stats at a national level, so smaller populations are being used to represent the entire country. Often these sample populations do not include children, indegenous peoples, ethnic minorities or persons with disabilities--populations that also have higher levels of vision disorders. Another confounding factor is that standards for measuring visual acuity are not always consistent. In order to be most effective, there needs to be reliable screening methods for posterior segment diseases like glaucoma, diabetic retinopathy and AMD to find true cause of vision impairment. This is where telemedicine could be very useful on a global scale.
Between 2014-2016, 20% of 29 countries surveyed did not cover any eyecare services in their national health plan, while others had only minimal coverage
What to do about it: Increase access to care
One third of countries (59% low income or low- to middle-income) that completed the WHO eyecare service assessment tool (ECSAT) between 2014–16 reported that there were no government measures in place to ensure equal distribution of health workers involved in eyecare in all geographic areas. Because of a lack of complete and accurate information, decision-makers at all levels of the health system may lack the information they need to identify needs, allocate resources optimally or provide evidence-based services.
Expand priority services
Research to ensure that areas of countries who have greatest need for eyecare are those that are getting it (ie if hospitals are only in larger cities, this still limits care to a significant portion of the population that might live in rural areas)
Reduce out-of-pocket payments
Eyecare needs to be included in national health care programs—the cost of ocular medications, surgeries and glasses can be prohibitively expensive even if there is a hospital where the patient could go
Eyecare services are frequently led by charitable organizations and nongovernmental organizations that act independently from ministry of health: this makes it difficult to track and may not be using resources where they are most needed
- Perform screenings in areas where people reside—i.e., if women more at risk for trachoma, screenings should be targeted in places women spend time
- After screenings, need referrals to primary, secondary and tertiary centers as care necessitates
- Public/private sectors need to work together
- Establish educational programs for optometry: ⅓ of countries surveyed showed optometry either not established as a profession or no educational requirements
Improving access to eyecare has a dual-fold financial benefit: increased productivity as those with prior vision impairments can participate in the workforce and also creates jobs in the health field to meet these needs. WHO is developing interventions for countries to use to develop these systems that include eyecare services in a manner that is both universal as well as cost-effective to both country and individual. This includes the OneHealth Tool, adding eyecare services to be used by countries for planning of services needed and rendered.
Out-of-pocket payments for health services push 100 million people into extreme poverty every year (110).
While this report discusses needs on a global level and creates a framework for countries to systematically plan for inclusion of eyecare services and their provision to all, there are some extrapolations that can be made as to what we can do as optometrists in the United States. This report acknowledges the fact that much of the outreach that is needed is unable to be performed by the country itself. In this way, international eye clinics, although short term, can still provide much needed glasses and referrals for cataract or other ocular disease. The other point that stands out is the great need in all countries, especially in rural areas, low income communities and within ethnic minority communities. We can all find somewhere close to home that fits this description and find ways for our services to be utilized to those most in need.
Although this report does show that great progress has been made in many areas, such as the reduction of vision impairment secondary to trachoma, we still have a long way to go to eliminate vision impairment and blindness. Finding ways to get involved on a policy level whether at the local or state level or influencing the field of optometry around the world is a real way to ensure those who need eyecare most are being reached. National planning globally must take into account that in many places, those performing eyecare are not optometrists or ophthalmologists. Many primary care providers, nurses and lay people are trained in various areas of eyecare including vision and ocular disease screening, refractions, telemedicine. Whatever way you get involved, know that what you do as an optometrist has a significant impact on the lives you touch, so keep getting out there to make a difference.