Ines Serrano MD Evan Waxman MD PHD Blindness Ines Serrano MD Evan Waxman MD PHD

"There is no better way to thank God for your sight than by giving a helping hand to someone in the dark.” Helen Keller

Every five seconds one person in the world goes blind Every five seconds one person in the world goes blind. One child goes blind every minute. http://www.who.int/mediacentre/news/releases/pr79/en/ http://www.who.int/mediacentre/news/releases/pr79/en/

Facts According to WHO: http://www.kernersvillerotary.org/images2009/052107BlindSchool7.JPG According to WHO: It is estimated that over seven million people become blind every year. 75% of blindness is avoidable 80% of visual impairment is avoidable 63% of those with low vision and 82% of blind people are over 50 years of age Of the six WHO regions, South East Asia and Western Pacific account for 73% of moderate to severe visual impairment and 58% of blindness.   http://www.kernersvillerotary.org/images2009/052107BlindSchool7.JPG http://www.who.int/topics/blindness/en/ http://www.who.int/topics/blindness/en/

Key Facts About 285 million people are visually impaired world wide, 39.8 million of them are blind Most of the people with visual impairment are older, and females are more at risk at every age, in every part of the world. 90% of people with visual impairments live in developing countries http://www.who.int/mediacentre/factsheets/fs282/en/index.html http://www.who.int/mediacentre/factsheets/fs282/en/index.html

Key Facts Cataract remains the leading cause of blindness globally, except in the most developed countries. Cataract surgery and correction of refractive errors are among the most cost-effective health interventions. http://www.who.int/features/factfiles/vision/04_en.html http://www.who.int/features/factfiles/vision/04_en.html

Key Facts 1.4 million children under age 15 are blind. Correction of refractive errors could give normal vision to more than 12 million children (ages 5-15). The number of people blinded by infectious diseases has been greatly reduced. Age related impairment is increasing. Blinding trachoma affects 40 million people today, compared to 360 million in 1985. http://www.who.int/features/factfiles/blindness/blindness_facts/en/index7.html http://www.who.int/features/factfiles/blindness/blindness_facts/en/index7.html

DEFINITION A key issue in any discussion of blindness is its definition. The elements of this definition that need attention are level of distance visual acuity, presenting or best-corrected visual acuity visual field constriction. In the United States, legal blindness is defined as distance visual acuity ≤20/200. Tasman, Duane's Ophthalmology, Lippincott Williams & Wilkins ( 2005)

Definitions (ICD-10):H54 Low Vision: Visual acuity of less than 6/18 but equal to better than 3/60 or corresponding visual field loss to less than 20 degrees in the better eye with the best possible correction Blindness: Visual acuity <3/60 or a corresponding visual field loss to less than 10 degrees in the better eye with the best possible correction. Visual Impairment Includes low vision as well blindness http://www.who.int/bulletin/volumes/82/11/en/844.pdf http://www.who.int/bulletin/volumes/82/11/en/844.pdf

DEFINITION This definition, based on best-corrected visual acuity, excludes the large number of people worldwide who are visually impaired due to uncorrected refractive error. Visual field constriction, independent of visual acuity, causes functional impairment. The inclusion of visual field criteria in the definition of blindness is recommended by the ICD-10 Visual fields are difficult to assess and many studies have not included visual field constriction in estimates of the prevalence of visual impairment.

VISUAL FUNCTION In addition, visual function is comprised of many other components. These include visual field color perception stereoacuity glare recovery dark adaptation contrast sensitivity function. These qualities of vision are not commonly assessed in population based visual impairment prevalence studies

Levels of Visual Function 1.- Normal vision 2.- Moderate visual impairment 3.- Severe visual impairment 4.– Blindness http://www.who.int/mediacentre/factsheets/fs282/en/ http://www.who.int/mediacentre/factsheets/fs282/en/

Proposed revision of categories of visual impairment Category Worse than Equal or better than Moderate or visual impairment 3/10 (0,3) 1/10 (0,1) 20/70 6/60 1/10 (0.1) 20/200 Severe Visual Impairment 3/60 1/20(0.05) 20/400 Blindness 3 1/60 1/50(0.02) 5/300 (20/1200) Blindness 4 Light perception Blindness 5 No light perception http://www.who.int/blindness/Change%20the%20Definition%20of%20Blindness.pdf http://www.who.int/blindness/Change%20the%20Definition%20of%20Blindness.pdf

The distribution of blind all ages in the six WHO Regions (millions) http://www.who.int/blindness/table/en/index.html http://www.who.int/blindness/table/en/index.html

http://www.who.int/blindness/causes/en/ http://www.who.int/blindness/causes/en/

http://www.who.int/mediacentre/factsheets/fs282/en/ http://www.who.int/mediacentre/factsheets/fs282/en/

Blindness Children causes 1.4 million children under age 15 are blind. The major causes of blindness in children vary widely from region to region and are largely determined by socioeconomic development, the availability of primary health care and eye care services. The available data suggests that, worldwide, corneal scarring is the single most important cause of avoidable blindness in childhood, followed by cataract and ROP. http://www.who.int/bulletin/archives/79(3)227.pdf http://www.vision2020kano.org/wp-content/uploads/2009/07/african-child-blind1-300x204.jpg http://www.who.int/bulletin/archives/79(3)227.pdf http://www.vision2020kano.org/wp-content/uploads/2009/07/african-child-blind1-300x204.jpg

CATARACT http://www.who.int/entity/blindness/causes/cata%20djib%2096.JPG http://www.who.int/entity/blindness/causes/cata%20djib%2096.JPG

CATARACT The primary function of the ocular lens is to transmit light and to focus it on the retina. A cataract occurs when the lens loses its clarity such that visual acuity is compromised. Cataracts can result from genetic, metabolic, nutritional, or environmental insults or can be secondary to other ocular or systemic conditions, such as diabetes. The most important risk factor is age; age-related cataract constitutes the great majority of all cataracts. Cataract remains the leading cause of blindness globally. Tasman, Duane's Ophthalmology, Lippincott Williams & Wilkins ( 2005)

CATARACT

CATARACT TREATMENT There are no medications or eye drops to treat cataracts. Cataracts never get better on their own. Treatment for cataract is surgery to remove the cloudy lens and replace it with clear artificial lens. The surgery is usually performed on an outpatient basis under local anesthesia. Cataract surgery is one of the most cost-effective health interventions.

GLAUCOMA Author’s clinical photograph

GLAUCOMA Glaucoma is a group of diseases which results in progressive damage to the optic nerve. Optic nerve damage leads to slow irreversible constriction of peripheral vision and, if untreated, blindness. Optic nerve damage can be seen as excavation or ‘cupping’ of the optic nerve head. Glaucoma is often but not always associated with elevated intraocular pressure.

GLAUCOMA

GLAUCOMA TREATMENT Glaucoma can be controlled by lowering intraocular pressure using Medication (eye drops) Laser therapy Surgery

AGE-RELATED MACULAR DEGENERATION http://www.aao.orgmedialibrary http://www.aao.orgmedialibrary

AGE-RELATED MACULAR DEGENERATION Age related macular degeneration (AMD) results in progressive damage to the macula, the small area in the retina responsible for sharp and central vision. The major risks for AMD are age and family history. AMD causes central vision loss. Central vision is critical for reading and recognizing faces AMD is the leading cause of irreversible blindness in industrialized countries.

AGE-RELATED MACULAR DEGENERATION

AGE-RELATED MACULAR DEGENERATION Dry AMD is characterized by progressive atrophy of the retinal pigment epithelium, accumulation of retinal metabolic products and loss of retinal photoreceptor function. Dry AMD can be slowed using a combination of Vit A, Vit E, Vit C, Zinc and Copper. Wet AMD is characterized by bleeding underneath the retina Wet AMD is treated by injection of anti Vascular Endothelial Growth Factor antibodies into the eye

DIABETIC RETINOPATHY Author’s clinical photo

DIABETIC RETINOPATHY Diabetic retinopathy (DR) is the leading cause of blindness in people of working age in industrialized countries. DR can be a complication of diabetes type1 or type 2. DR results from damage to the blood vessels of the retina, the ‘photographic film’ of the eye. Initially, DR is asymptomatic. If not treated though it can cause low vision and blindness. Risk factors associated with DR include duration of diabetes and poor blood sugar control.

DIABETIC RETINOPATHY TREATMENT The best treatment for DR is prevention – control of blood sugar Once DR threatens vision treatments can include: Laser therapy to seal leaking blood vessels (focal laser) Laser therapy to reduce retinal oxygen demand (scatter laser) Surgical removal of blood from the eye (vitrectomy)

Trachoma http://www.aao.orgmedialibrary http://www.aao.orgmedialibrary

TRACHOMA http://www.vision2020.org/image/Diagrams/global%20active%20may%202006.jpg Trachoma is caused by infection of the ocular surface by the bacteria Chlamydia trachomatis serotypes A-C. Chlamydia trachomatis is endemic in many countries of Africa Middle east, South America, and Asia. Trachoma can cause a severe inflammation of the ocular surface resulting in scarring of the eyelids. This causes eyelashes to grow in the wrong direction and rub the cornea (clear front ‘window’ of the eye) Multiple reinfections can cause scarring and opacity of the cornea. http://www.vision2020.org/image/Diagrams/global%20active%20may%202006.jpg

http://www.cartercenter.org/images/BLINDch_web.gif http://www.cartercenter.org/images/BLINDch_web.gif

TRACHOMA TREATMENT The World Health Organization (WHO) recommends carrying out an initiative called ‘SAFE’. SAFE stands for: Surgery to repair damage to the eye. Antibiotics to treat the infection. Face washing to reduce the spread of infection. Environmental changes, such as providing access to clean water and suitable sanitation. Mass antibiotic treatment with single-dose oral azithromycin reduces the prevalence of active trachoma and ocular infection in communities. http://www.who.int/blindness/causes/trachoma/en/index.html http://www.who.int/blindness/causes/trachoma/en/index.html

Onchocerciasis http://www.unep.org/yearbook/2004/097.htm

ONCHOCERCIASIS Onchocerciasis, also known as river blindness, is caused by the filarial nematode Onchocerca volvulus This worm is transmitted by the Simulium black fly, which breeds in the rivers and streams of Africa, Brazil, Mexico, the Middle East, and parts of Central America. Onchocerciasis is endemic in at least 27 sub-Saharan African countries, and in Yemen Studies indicate that most eye clinical manifestations occur in response to degenerating microfilariae and the release of endosymbiotic Wolbachia bacteria. http://whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf http://whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf

http://www.dpd.cdc.gov/dpdx

Onchocerciasis Treatment The treatment for onchocerciasis is ivermectin. A single dose of ivermectin needs to be taken annually to be effective Targeting endosymbiotic Wolbachia species has emerged as as a new approach in the control of onchocerciasis Onchocerca embryogenesis is completely dependent on the presence of Wolbachia, studies of doxycycline therapy (100–200 mg/d for 6 wk) have shown great promise. http://www.who.int/entity/pbd/blindness/onchocerciasis/en/onchocerca_volvulus.jpg Saint André A, Blackwell NM, Hall LR, Hoerauf A, Brattig NW, Volkmann L, Taylor MJ, Ford L, Hise AG, Lass JH, Diaconu E, Pearlman E. The role of endosymbiotic Wolbachia bacteria in the pathogenesis of river blindness. Science. 2002 Mar 8;295(5561):1892-5 http://www.who.int/entity/pbd/blindness/onchocerciasis/en/onchocerca_volvulus.jpg

Retinopathy of Prematurity http://www.aao.orgmedialibrary http://www.aao.orgmedialibrary

Retinopathy of Prematurity (ROP) ftp://ftp.nei.nih.gov/eye_exam/exam13_150.tif ROP is a disease that affect s a premature infants and is an important cause of childhood blindness in developed countries. Retinopathy of prematurity (ROP) results from damage to the retina due to incomplete development of retinal blood vessels prior to birth The primary risk factor for ROP is low gestational age at birth and the smaller a baby is at birth the more likely that the baby is to develop ROP. Major risk factors • Low birthweight (less than 1500 grams) • Low gestational age (32 weeks or less) Over 80% of infants born at less than 28 weeks’ gestational age develop ROP and 60% of infants born at 28−31weeks develop ROP. Y

Retinopathy of Prematurity ftp://ftp.nei.nih.gov/eye_exam/exam12_150.tif Successful treatment for ROP requires early detection and timely laser therapy by skilled practitioners Despite improvements in detection and treatment, ROP remains a leading cause of lifelong visual impairment among children in developed countries

Vitamin A deficiency http://motherchildnutrition.org/malnutrition/images/xerophthalmia.jpg http://motherchildnutrition.org/malnutrition/images/xerophthalmia02.jpg http://motherchildnutrition.org/malnutrition/images/xerophthalmia.jpg http://motherchildnutrition.org/malnutrition/images/xerophthalmia02.jpg

Vitamin A deficiency Vitamin A deficiency (VAD) can result in Xerophthalmia (severe dryness and scarring of the eye), corneal ulceration and perforation (keratomalacia) and night blindness VAD is the single most important cause of childhood blindness in developing countries. An estimated 2.8 million preschool-age children are at risk of blindness from VAD Vitamin A supplements at a cost of only 5 US cents a dose, can reduce child mortality by up to 34% in areas where Vitamin A deficiency is a public health problem http://www.who.int/blindness/causes/priority/en/index4.html http://www.who.int/blindness/causes/priority/en/index4.html

Latin America and the Caribbean In Latin America and the Caribbean, cataract (opacification of the lens) is the single most important cause of blindness; cataract surgery has been shown to be one of the most cost effective interventions of all health care interventions http://www.who.int/bulletin/volumes/82/11/en/844.pdf http://www.who.int/bulletin/volumes/82/11/en/844.pdf Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, Mariotti SP. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004 Nov;82(11):844-51. Epub 2004 Dec 14.

Africa Blindness prevalence rates vary widely but the evidence suggests that approximately 1% of Africans are blind. This region is home to approximately 7.1 of the world’s 38 million blind. Approximately half the blindness in Africa is due to cataract. Although trachoma has been declining in many areas of the world, it still remains the second leading cause of blindness in Africa. http://www.who.int/bulletin/volumes/82/11/en/844.pdf http://www.who.int/bulletin/volumes/82/11/en/844.pdf Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, Mariotti SP. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004 Nov;82(11):844-51. Epub 2004 Dec 14.

North America and Western Europe Most adult visual impairment in North America and Western Europe is related to age-related macular degeneration and diabetic retinopathy. While both of these conditions are subject to treatment, neither can be cured. http://www.who.int/bulletin/volumes/82/11/en/844.pdf http://www.who.int/bulletin/volumes/82/11/en/844.pdf Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, Mariotti SP. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004 Nov;82(11):844-51. Epub 2004 Dec 14.

Blindness challenges in developing countries http://www.who.int/entity/blindness/causes/ChildhBlind%2096.JPG Blindness is particularly devastating in the developing world where it has a profound impact on the quality of life for the blind person and his or her community. The majority of blind people in developing countries live in remote areas, while most of the eye care providers and hospitals are situated in the cities. Women and children face extra challenges, including limited access to financial resources and health information, fewer travel options, and less social support in seeking care. http://www.cureblindness.org/world-blindness http://www.cureblindness.org/world-blindness

Blindness in the developing world http://www.who.int/entity/apoc/media/onchocerciasis_blindness_thumb.jpg 90% of blind people in the developing world can not work. 50% report a reduced of social status and decision-making authority. Blind people in the developing world are subject to low employment, inadequate housing, substandard health care, barriers to education, cultural activities, sports and recreation Life expectancy is half or less than age matched sighted individuals Canadian research showed that people with irreversible visual loss are twice as likely to fall, four times as likely to fracture a hip, three times as likely to suffer clinical depression and twice as likely to die as those of similar age with good sight http://www.cureblindness.org/world-blindness/ http://www.cureblindness.org/world-blindness/

Education Approximately 90% of visually impaired children in low-income countries are deprived of an education. Lack of infrastructure, affordable health care, production of accessible and suitable school materials and qualified teachers prevent visually impaired children from attending school http://www.dit.ie/mozambique-eyecare/developmentandeyecare/ http://www.dit.ie/mozambique-eyecare/developmentandeyecare/ http://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2008/11/21/Blind-children.jpg http://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2008/11/21/Blind-children.jpg

VISION 2020 VISION 2020 is the global initiative for the elimination of avoidable blindness, a joint program of the World Health Organization (WHO)and the International Agency for the Prevention of Blindness (IAPB) with an international membership of NGOs, professional associations, eye care institutions and corporations. http://vision2020.org/main.cfm http://vision2020.org/main.cfm

http://www.ophed.com/group/2205 The Guerrilla Eye Service of the UPMC Eye Center is dedicated to eliminating barriers to eye care for patients in the Western Pennsylvania area. http://www.ophed.com/group/2205

"Alone we can do so little, together we can do so much.” http://www.kilimanjaro-blindtrust.org/pictures/school10.JPG "Alone we can do so little, together we can do so much.” Helen Keller

References http://www.who.int/topics/blindness/en/ http://www.who.int/mediacentre/news/releases/pr79/en/ http://whqlibdoc.who.int/bulletin/2001/issue3/79(3)227-232.pdf http://www.who.int/blindness/en/index.html http://www.nature.com/eye/journal/v19/n10/full/6701973a.html http://www.who.int/mediacentre/factsheets/fs282/en/index.html http://www.who.int/features/factfiles/vision/04_en.html http://www.who.int/features/factfiles/blindness/blindness_facts/en/index7.html http://www.who.int/bulletin/volumes/82/11/en/844.pdf http://www.who.int/topics/blindness/en/ http://www.who.int/mediacentre/news/releases/pr79/en/ http://whqlibdoc.who.int/bulletin/2001/issue3/79(3)227-232.pdf http://www.who.int/blindness/en/index.html http://www.nature.com/eye/journal/v19/n10/full/6701973a.html http://www.who.int/mediacentre/factsheets/fs282/en/index.html http://www.who.int/features/factfiles/vision/04_en.html http://www.who.int/features/factfiles/blindness/blindness_facts/en/index7.html http://www.who.int/bulletin/volumes/82/11/en/844.pdf

References http://www.who.int/mediacentre/factsheets/fs282/en/ http://www.who.int/bulletin/archives/79(3)227.pdf http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001860/frame.html http://whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf http://www.who.int/blindness/causes/priority/en/index4.html http://www.cureblindness.org/world-blindness http://www.vision2020.org/main.cfm http://www.dit.ie/mozambique-eyecare/developmentandeyecare/ http://vision2020.org/main.cfm http://www.who.int/mediacentre/factsheets/fs282/en/ http://www.who.int/bulletin/archives/79(3)227.pdf http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001860/frame.html http://whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf http://www.who.int/blindness/causes/priority/en/index4.html http://www.cureblindness.org/world-blindness http://www.vision2020.org/main.cfm http://www.dit.ie/mozambique-eyecare/developmentandeyecare/ http://vision2020.org/main.cfm

References Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, Mariotti SP. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004 Nov;82(11):844-51. Epub 2004 Dec 14. Saint André A, Blackwell NM, Hall LR, Hoerauf A, Brattig NW, Volkmann L, Taylor MJ, Ford L, Hise AG, Lass JH, Diaconu E, Pearlman E. The role of endosymbiotic Wolbachia bacteria in the pathogenesis of river blindness. Science. 2002 Mar 8;295(5561):1892-5 Tasman, Duane's Ophthalmology, Lippincott Williams & Wilkins ( 2005) Yanoff, Duker, Augsburger Ophthalmology, Mosby 2003.