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Who's afraid of prevention of blindness?
  1. DONALD TAN
  1. Corneal Service, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751

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    In this new millennium, the post-genomic era is likely to herald significant advances and changes in the field of ophthalmology research. Wave front deviation guided LASIK to enhance visual acuity, gene knockout therapy for AMD, and ex vivo clonal expansion of limbal stem cells for ocular surface reconstruction are just some of the exciting developments on our horizon. Where then lies any interest in prevention of blindness (POB) programmes? Can research in ocular epidemiology have an impact any longer with young ophthalmic residents, and who attends the POB session at ophthalmic meetings?

    Think of cataract, and one usually thinks of the latest chop, or flip flop technique of nucleus removal within an elegant clear corneal, topical phacoemulsification procedure, not cataract camp surgery in India. And yet, in this new age of technological success and innovation, more people than ever before will continue to go blind from cataract by simply not having access to surgery. Hugh Taylor estimated in 1995 that five out of six people blind from cataract die before they receive cataract surgery.1 Age related blindness from cataract now accounts for 50% of blindness in the world, and because only 20% of those blind from cataract currently have access to cataract surgery, mass blindness will double in number to 80 million people within 10 years.2 The impact of world blindness unfortunately is usually not felt in developed countries. Of the 37.9 million blind in the world, reported by the World Health Organization in 1995, 75% live in the developing countries of Asia (21.4 million) and Africa (7.1 million), and at least 50–70% of adult blindness are either preventable or curable with currently available medical or surgical technology.3

    As doctors trained to alleviate suffering and disease within an increasingly global society, we need to step back from our busy clinical workloads and clinical trials, and focus on these startling statistics. After all, Lim stated that “the movement to alleviate cataract related blindness should excite everyone, for it is about humanity: the willingness to help the less fortunate. It is about human organization. It is about international cooperation.”2Faal and coworkers in this issue of the BJO(p 948) describe the profound impact of a national eyecare programme (NECP) on the prevalence of blindness and low vision in the Gambia. In a return survey 10 years after the initial survey, they report a 40% reduction in the crude prevalence of blindness from 0.70% to 0.42%, and show that this reduction is mainly due to a significant drop in the prevalence of cataract blindness in the western health region, where the NECP was started. This POB programme clearly illustrates how a carefully planned intervention in preventive healthcare policy specifically targeted at reducing the burden of blinding cataract can result in significant reduction of blindness on a national scale.

    The success of the NECP hinges on two important factors, the training of village health workers in primary eye care, and the training of a paramedic cadre of ophthalmic medical assistants to perform cataract surgery. Establishment of an effective training programme for local ophthalmic personnel to perform cataract surgery is of paramount importance for long term success, and this was also clearly illustrated by the formation of training centres for cataract surgery in the People's Republic of China. Ten years ago, the concept of a training centre in China to teach extracapsular cataract extraction and posterior chamber implant was developed, and in 1989, the International Intraocular Implant Training Centre was established in Tianjin. With the cooperation of regional hospitals, it has been the training centre for 1500 ophthalmologists, and its programmes have restored normal vision to 20 000 cataract patients in Tianjin and in the affiliated regional hospitals whose ophthalmologists were trained at this centre.2

    In India, too, significant changes are afoot. In 1996, the World Bank announced a historic programme to solve the problem of cataract blindness in India. The goal, to restore vision to 11 million cataract victims in 5 years, involved a loan exceeding $100 million to the Indian government, to be spent on training seven medical colleges and 1500 government surgeons to perform extracapsular cataract extraction.4

    Wormald, in a recent BJO editorial, commented on quantity and quality of cataract surgery, and stated that while output may be increased and costs are reduced, quality must be maintained or improved.5 Within this epoch of phacoemulsification, the change in less developed countries from intracapsular cataract extraction (ICCE) to extracapsular cataract extraction (ECCE) with intraocular lens implantation in Africa, China, and India finally signifies the close of an era in which uncorrected aphakia was responsible for a significant cause of visual disability even after surgery. Alfred Sommer reported a decade ago that “at least half of the people who have undergone allegedly successful surgery are blind, because they do not have aphakic glasses”,4 and Faal's study also suggests that the highest proportion of uncorrected aphakia occurring in the Western region (19% of blindness) is directly related to the fact that ICCE was the dominant procedure during the first 5 years of the NECP.

    Let us then remind ourselves of prevention of blindness programmes which have the potential to do the greatest good for the most people. Sir John Wilson, recipient of the 1997 Jose Rizal Gold Medal, the highest award of the Asia-Pacific Academy of Ophthalmology said:

    “Increasingly, it is likely that the prevention of blindness will be seen, not as an exclusive initiative, but as the model for more comprehensive action against all causes of avoidable disability which affect massive populations.”6

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