Category Archives: Vision 2020
Glaucoma is the second leading cause of blindness worldwide, after cataract. But unlike cataract, the blindness caused by glaucoma is irreversible. That’s why identifying the condition early and treating it effectively is vital to save sight.
In this blog, the second in our series showcasing how CBM is helping achieve the Vision 2020 targets towards eliminating avoidable blindness, CBM glaucoma specialist Heiko Philippin, who is based in Tanzania, East Africa, talks about his work treating glaucoma in Africa.
I started working at KCMC in Tanzania in December 2009. Each year, we carry out around 2,500 glaucoma examinations, some of the patients come repeatedly – so 1000-1500 patients with glaucoma each year. Around 100 or less would be children with paediatric glaucoma.
The main challenges are that patients present late – there are numerous different reasons for this – and that treatment options can be limited.
CBM is supporting the management and treatment of glaucoma at a number of different levels. Treating glaucoma is challenging – the condition requires life-long treatment and follow up. In large parts of Africa, we do not have all of the treatment options available as in Europe for example, though at KCMC we have a reasonable amount of treatment options, especially now also with the new laser treatment.
The appropriate treatment option depends on the age group, the stage of glaucoma and the amount of eye pressure reduction which is necessary. We usually start with eye drops or laser, if these are not feasible or not enough then surgical options come into place, mainly a procedure called trabeculectomy. Shunts, which reduce the pressure, are usually only used in desperate cases.
The choice of eye drops is limited in Africa compared to in Europe. In a lot of areas in this region, we only have one type of drop available, while in Europe there are 6 different groups of eye drops available. Over the years things have definitely improved in larger urban centres, though. At KCMC we can offer 4 different types of eyedrops, but this is not common.
The second group of treatment is laser – this is also limited – and the last treatment option is surgery. The most common is trabeculectomy; we can offer our services at similar standards as in any other country.
The next improvement is that we are planning to offer tubes (shunts) which reduce the eye pressure. Aravind in India has now developed a low cost shunt. Often the patient will have tried eye drops and laser before this option
CBM has helped with the procurement of eye drops, which are often not part of standard procurement, and has helped finance larger equipment, which would not be possible otherwise.
CBM has also supported training – I have received specialist training and now offer fellowships in Glaucoma to doctors in Sub Saharan Africa. CBM also offers training to ophthalmologists including the treatment of glaucoma.
I am currently running a trial for a treatment called Selective Laser Trabeculoplasty (SLT), thanks to a joint grant from Standard Chartered’s Seeing is Believing programme and CBM. SLT has been in use in the UK and elsewhere for several years, but this is the first time it is being trialled in Sub-Saharan Africa. We want to find out if the laser treatment is equal or better than the standard treatment which is currently available here. If it is equal or better, then the laser treatment will offer pressure reduction for one or probably more years without the need for the patient to come back every few months for eye drops. Patients are often not able to take the eye drops for different reasons, so we are hoping that the overall treatment of glaucoma will improve.
Of the patients I see, 100 or less are children. They often have a different type of glaucoma, they can have congenital glaucoma or secondary glaucoma due to other eye problems, both are challenging to treat.
I see a lot of patients who are blind according to the WHO definition – visual acuity of less than 3/60 – roughly they could count fingers up at a distance of 3 meters. If you use this definition then a lot of my patients I see are legally blind.
Glaucoma patients who have low vision or even have no visual function left, who cannot differentiate between light and darkness we refer to the low vision department, where we advise on low-vision devices so that they are able to do daily activities better. We can also assist for example in using a cane so they can move around more safely, and we refer them to CBM partners, Tanzanian Society for the Blind.
By Professor Allen Foster, Professor of International Eye Health, Co-Director of the International Centre for Eye Health for London School of Hygiene and Tropical Medicine and former President of CBM International.
The World Health Organisation in 2010 estimated that there are 39 million blind people in the world, but in 80% of these cases the blindness can be prevented or treated. In the year 2000 the WHO together with a group of International Non-Government Organisations, including CBM, launched “VISION 2020 – the right to sight”, a 20 year initiative to eliminate avoidable blindness in the world. So what are the results?
There have been good successes, in fact in 2000 the projected number of blind people in the world for 2010 was well over 50 million, so the actual 2010 figure of 39 million has to be seen as an improvement. There have been good results to control diseases like river blindness (onchocerciasis), vitamin A deficiency (in children) and trachoma, all of which were major causes of blindness in poor countries. There have also been improvements in the delivery of eye care services generally around the world, but particularly in the middle income countries of Asia and Latin America. However the fact remains that about half of all blindness, around 20 million people, is due to cataract which is very treatable.
Cataract occurs when the clear lens in the eye opacifies, becoming like a frosted window. There are a variety of causes, but most cataract is associated with the aging process – the older we get the more likely we are to develop cataracts.
The good news is that the cataract can be removed and its function to focus light on the retina can be replaced by a small artificial lens placed inside the eye (intra-ocular lens) at the time of surgery. The operation is safe and has a very high success rate so that most people have excellent restoration of sight providing the eye has no other problems.
So if the operation is so good why are there 20 million people around the world blind with cataract? The main reason is poverty. Many low income countries do not have enough trained eye specialists. For example in the UK there are about 20 eye specialists for every million people while most African countries have only 1 to 3 eye specialists per million people; and those that are available, for family reasons, tend to work in larger cities which is often far away from poor people living in rural areas.
In order to make cataract surgery available to blind people CBM has been supporting the training of ophthalmologists, cataract surgeons, eye assistants and nurses throughout Africa for many years. A lot has already been achieved; for example in Tanzania there used to be 5 ophthalmologists when CBM started to support eye training and now there are 35 together with over 60 trained cataract surgeons and more than 300 eye nurses / assistants; however there is much more to be done if the goal of VISION 2020 to eliminate avoidable blindness by 2020 is achieved.
It is estimated that Africa needs another 2,000 eye specialists (to achieve 4 specialists per million population) by 2020, but at present less than 100 are being trained each year. Without the eye surgeons, people will not be able to receive cataract surgery and the problem of blindness from cataract will continue. CBM in partnership with other like-minded organisations and Ministries of Health in Africa is seeking to address this urgent health need to train eye health workers for low income countries particularly in Africa.
Professor Dr. Allen Foster, former CBM International President (2006-13) and Medical Consultant/Director (1985-2005), is Professor in International Eye Health and Co-Director of the International Centre for Eye Health at the London School of Hygiene and Tropical Medicine. From 1975-1985, Allen was a general medical officer in a mission hospital in Tanzania. In 1998 he received an O.B.E. (Order of the British Empire) ‘For services to Ophthalmology in the developing world’.
I’m the Programme Manager for CBM UK and I visited Luz and her family when I was in Peru. I am enclosing a short report that I wrote after my visit.…
I met Jeick and his mother Luz at their home in Lima, Peru, where they live with Luz’s mother, four brothers and sisters and their children. A small space for such a large family.
Luz explained about the traumatic birth of Jeick which resulted in him being born prematurely at 27 weeks, weighing just over 1kg. Luz became upset as she described the experience which bought back memories of how she felt at the time, not knowing if her son was going to live or die, let alone see.
Luz had to leave Jeick in hospital after just three days, where he stayed for a further two months. She struggled to look after her other two children and visit the hospital every day to see Jeick. It took Luz an hour and a half to reach the hospital each day and the costs soon started to add up.
Luz showed us photos of Jeick from when he was born and still in an incubator. He looked so tiny and vulnerable.
Jeick was regularly screened for ROP where staff had been trained by CBM’s partners in Lima. At three months old he was diagnosed with ROP and given an urgent appointment. But by this point Luz could not afford to pay for the transport to hospital and so they could not make this first appointment.
When we stepped in to pay for her transport, our ophthalmologist was able to urgently conduct the laser treatment and after a short stay in hospital Jeick was able to return home.
It’s been over four months now since Jeick had his treatment and his vision continues to develop extremely well; early signs are that he will have good eye sight and potentially not even require glasses.
Luz told us how thankful she was for the treatment and support she received from CBM It was a real inspiration to meet Luz and hear about her experience and how CBM had made such a vital difference to their lives – not only had we provided sight saving treatment, but we also supported Luz in the rehabilitation process. Luz says she is very grateful for the treatment that Jeick received thanks to the programme and is very happy that her “angelito de diós” (little angel of God) is doing so well now.
Seeing Jeick now, you would never know what a traumatic experience he and his family went through. A real pleasure to see such a happy family.
For years, CBM has needed hard evidence on the economic impact of restoring vision, and now we have it.
A recently completed study in Kenya, Bangladesh and the Philippines showed that following a sight-restoring cataract operation, the average economic gain per family per year is £250. Not much by UK standards, but an awful lot of money for a Bangladeshi family.
It costs CBM about £20 to do one cataract surgery, so the return on investment is 1,500%!
In 2010, CBM and its local partners restored eyesight to 644,000 cataract blind people who would otherwise have remained blind, due to poverty. So a bit of maths shows that the global economic impact of CBM’s cataract surgical work comes in at about £160 million. Not bad at all!
Now, we have to get the message across to governments that restoring vision benefits their economies!
There are some fantastic new estimates coming out of the WHO that 39.8 million people are blind worldwide; which is a decrease of just over 5 million (13%) in the past 6 years!
Around 80% of blindness is avoidable (as in treatable or preventable); and 90% of blind people live in low income countries.
We are winning the war on blindness!
So I started the day as normal 5am, but this time with no strange animals or creatures in the house. Even my dog Ellie had gone on her weekly walkabout for a day or maybe two. A nice coffee, a beautiful sunrise and some paperwork and emails.
At 8am we had the big staff meeting/indaba to discuss the year ahead, tell everyone an update on Nick’s condition, and tackle any concerns that anyone might have. Was a great time to have everyone together in the same place, and closed with a nice prayer by Church elder Mr Banda.
We saw a few patients, and then lept into a series of meetings with senior staff, tax consultants, drivers, and cataract case finders. Finally we met with Stefan, CBM National Coordinator for Malawi and Dr Ter Haar the Nkhoma General Hospital Medical Director. It was a very productive day and we got a massive amount of issues sorted. I’m not a fan of having meetings for meetings sake, but find it a pleasure to sit down with all the staff and people involved with Nkhoma Eye Hospital, to really hammer out and resolve important issues. A real blessing to be able to do this now, as in 2 weeks time we will start to screen patients in the villages and bring them to Nkhoma for surgery or other help; and that is when we start to get very busy. Looking forward to it.
I have gathered strength from family and friends over the festive season, and am ready for the new year. It’s not going to be easy. We have much less funds, and I totally understand. With the past two year’s international financial crisis, we all perhaps have less to give; and this ultimately boils down to affecting Nkhoma Eye Hospital. Our goal will stay the same. To aim to tackle poverty by eradicating avoidable blindness, with our work in central Malawi. Make no mistake, we will find under-served and impoverished and blind people; and we will serve them. We will try our very best as the team in Malawi to make this happen, in spite of the reduced funds; and we will do it. But I have to say it makes me a bit sad that all this will slow down a little.