WHO: Need exists for data and accessible, affordable eye care

ORLANDO, Fla. – The World Health Organization feels challenged and feels a sense of urgency in light of the findings in its World Vision Report, which was shared here at the American Academy of Optometry meeting by Alarcos Cieza, MSc, MPH, PhD, coordinator of WHO Blindness and Deafness Prevention, Disability and Rehabilitation.

“We hope the eye care sector feels the same urgency for action that we at WHO feel,” Cieza said during the academy’s plenary session, which was partially sponsored by Healio/Primary Care Optometry News.

The content of this report does not provide the necessary information; it merely summarizes existing information that was collected, she said.

Eye conditions are universal, Cieza said. “Anyone who will live long enough will have an eye condition,” she said.

The data indicate that 196 million people worldwide have age-related macular degeneration, 146 million have diabetic retinopathy, 76 million have glaucoma, 2.8 million have Trachoma, 2.6 billion have myopia (312 million are younger than 18 years), and 1.8 billion have presbyopia.

“The significance of these numbers is that they portray the huge need for eye care around the world,” Cieza told attendees, “but we cannot even add them up because we know they overlap. We can’t say how many people total around the world have at least one eye condition.”

According to the World Vision Report, at least 2.2 billion people have vision impairment, and at least 1 billion have not received the care they need.

“Access is a big reason,” Cieza said, and “vision impairment is not distributed equally.”

It is four times higher in low income countries and more prevalent in rural areas, among women, the elderly, ethnic minorities, the disabled and indigenous populations.

Cieza said her colleagues from other programs cannot believe this situation exists among such a mature health sector. “How can this be?” they ask.

“There are many possible answers to this question, but one we have found over and over is that there is a lack of integration of the eye care sector, and this has consequences,” she said. “The eye care sector is often like a black box. You don’t know who needs care or who provides it, and one of the reasons for that is because it’s not even sometimes seen as an integral part of the health system.”

She said a large proportion of services are provided by the private sector, but without coordination with the public sector.

“Knowledge and information are not shared,” Cieza said. “We see an uncoordinated and unregulated workforce. Eight of the 24 countries from which we collect data do not recognize optometry as a profession or do not have educational requirements.”

She explained that countries typically have a national strategic plan divided into sectors.

“If eye care is not part of the health sector strategic plan, it will not be prioritized,” Cieza said. “We need to advocate to make sure that eye care is an integral part of the health sector strategic plan so it can be not only prioritized but integrated and considered in the planning,” she said.

Some countries have universal health coverage, but with budgets typically too small to cover all services for everyone, Cieza said.

“So the attempt is to cover at least some basic services so as many people as possible get the care they need without having to suffer hardship,” she said. “Still, basic interventions like cataract surgery or provision of glasses are not part of those packages of care.”

Cieza said it must be determined exactly how many people are in need of refractive care and cataract surgery and how many of those receive the care, with the intended gain of seeing well.

“It is not only about coverage, but effective coverage,” she said. “The intended outcomes need to be achieved. We have an opportunity; however, if we cannot provide the data we will miss this opportunity. That is why we see urgency for action.”

The World Report on Vision recommends:

• Make eye care an integral part of universal health coverage.
• Implement integrated people-centered eye care in health systems.
• Promote high quality research.
• Monitor trends and evaluate progress.
• Raise awareness and engage and empower people and communities.

“Thirty years from now we should not be where we are today,” Cieza concluded. “Read the report and tell WHO what you think.”

Ophthalmic professions must address uncorrected refractive error together

Kovin Naidoo, OD, MPH, PhD, FAAO, who also spoke during the plenary session, said optometrists, ophthalmologists, optical technicians and orthoptists must work together to address the problem of uncorrected refractive error around the world.

“We know there’s marginalization, either consciously or unconsciously, by ophthalmologists and optometrists about political battle,” said Singapore-based Naidoo, Essilor’s senior vice president for vision impact for philanthropy, former CEO of the Brien Holden Vision Institute and an editor of the World Vision Report.

“We don’t engage orthoptists and optical technicians,” he continued. “We should be looking at whether we should bring in our optical colleagues as part of our fraternity. We’ve adopted an adversarial approach. We need a new system in the way we see eye care.”

Naidoo said he has lived and worked in the developing world, but was trained as an optometrist in the U.S.

“I’ve seen both sides,” he said. “ My biggest pain about all of the work we’ve done in this space is that we fail to bring these different things together. We tend to want to be in different camps.”

He said the WHO report quantifies vision impairment due to refractive error based on a visual acuity cutoff of less than 6/12.

“This report states the number of people suffering from uncorrected refractive error in 2018 is 2.7 billion people, based on a 6/9 visual acuity cutoff to establish a needs-based model,” Naidoo said. “The WHO report doesn’t say we don’t address others’ needs, but we need to target people who cannot function or work because their vision is so bad.”

Globally, the relevance of optometry in public health systems is lacking, he said.

“There’s marginalization, pockets of success, but lack of scale,” he said.

The public health system of a country does not necessarily comprise only government components, Naidoo said.

“Private optometry, which is the majority of our profession in the developed world, is very much a part of the public health system,” he said.

Challenges include a limited number of optometrists, difficulties in producing optometrists, maldistribution and scope of training, he said.

Naidoo said optometrists in Kenya were opposing the training of some rural care givers.

“I asked the optometrists if they would go into these areas to provide care,” he said. “They said no, so let’s train people to increase access to services.”

The expertise of optometrists in the U.S. “is a huge public benefit to the world if we can export that in an effective way,” Naidoo said.

With uncorrected refractive error as the second leading cause of blindness, optometry has, “an opportunity to change the numbers like no other profession in the world,” Naidoo said.

By 2050 half of the world’s population will be myopic, with 10% of those people having high myopia.

“That is in your hands and my hands,” he said, and it covers all aspects of eye care.
“It’s about research, clinical services with myopia control, it’s about public health ensuring there’s access,” Naidoo said. “You have to get to that kid quickly. Access is important. The quicker they get the prescription, the quicker we can control the myopia group.”

He noted that the government in Taiwan is instituting laws requiring schoolchildren to have 2 hours a day outdoors.

“It’s creating a new advocacy option to place optometry on the center stage of eye care for us to make a difference to our world,” Naidoo said.

“In the modern world, there will be two major public health issues, myopia and diabetes,” he continued. “Diabetes is growing; it’s tracking myopia. Myopia is firmly in our hands. Diabetes impacts our patients in significant ways and will add to the blindness and vision impairment data unless we ensure the scope of care you provide is the scope of care every poor person in the world is getting access to – dilated fundus exams during intervention, exams on a regular basis.”

School eye health has been on the global health and education agendas, Naidoo said.

“One of the biggest budgets Essilor spends is to support school eye health programs and to support optometrists to do programs in the U.S. for children who cannot afford eye care,” he said. “This is an agenda that the world report is talking about, and you and I are involved in this.”

We need to think differently to support the need around the world, Naidoo said.

“We need to connect primary vision care providers to qualified optometrists and ophthalmologists who remotely oversee the refraction process in real time,” he said. “Using a telerefraction platform with a table/mobile phone, they have a trial lens set, an objective measurement device and an acuity chart. Technology doesn’t have to be our enemy; it can be an opportunity. Local people could have local businesses providing these services.”

Naidoo concluded: “Optometry should review the report as an opportunity, not a challenge.”

U.S. must improve surveillance of vision problems

Sandra Block, OD, MPH, FAAO, who was also an editor of the World Vision Report, said the U.S. must do a better job at identifying the true magnitude of the vision problem in the country.

Block is also a professor at Illinois College of Optometry and was one of the authors of the first vision report from the National Academies of Sciences, Engineering and Medicine.

“The magnitude of myopia is growing,” she said during the plenary session. “Surveillance in the U.S. is not at a level we need. Here the world report on vision is talking about having a better number we can report on.”

We have done a great job at collecting data, “but is it the right data?” Block asked. “The CDC has started to work on that, but there’s a long way to go. Optometry needs to do a better job contributing to the data that’s out there.”

She continued, “The impact of visual impairment is far greater than we ever thought about. The world report on vision has some key messages, and one is universal health coverage. We need to think about models that do a much better job of integrating eye care into the health care system. We need to think about addressing increasing demand as the number of people who are vision impaired and blind increases; we need to think about how we can address their needs better.”

When WHO comes out with a report, the question is always how it affects the U.S. as a country, Block said.

“The fact is we think egocentrically,” she said. “Things are different here. But the reality is we do need to think about where we fit into the big picture.”

One of WHO’s sustainable development goals is universal health coverage, “ensuring everyone has access to eye care without it affecting them financially,” Block said.

Universal health coverage is a “birth-to-death” concept, she said. “The earlier you identify a vision problem in a child, the more likely the outcomes will be better. They will impact the academic performance of a child.”

The prevalence of chronic vision impairment in the U.S. is strongly age-related, Block said, and vision impairment is associated with cognitive decline.

“As people get older, they have multiple chronic conditions and this ultimate geriatric syndrome,” Block said. “We worry that the more conditions you have, the more likely you’ll be hospitalized or experience early death.

“Vision impairment leads to decreases in physical, cognitive, social and physiological function, leading to frailty, disability, comorbidity and mortality,” she said. “If we do a better job of identifying vision impairment, we can affect their outcomes.”

Other vulnerable populations include those with disabilities, those who live in rural communities, the poor and the indigent, Block said.

“We need to do a better job to expand services and invest more appropriately,” she said. “We need to move away from the siloed services to a continuum of care that is patient-centered.” – by Nancy Hemphill, ELS, FAAO

Reference:

McMahon T, et al. Plenary session: Today’s research, tomorrow’s practice, WHO World Vision Report, opportunities for optometry to make an impact. Presented at: American Academy of Optometry meeting; Orlando, Fla.; October 23-27, 2019.

Disclosure: Block reports no relevant financial disclosures. Cieza is employed by WHO. Naidoo is employed by Essilor.