Excerpts from "A New Paradigm for Primary Eye Care in Developing Countries and Medically Underserved Areas"
-Ian B. Berger, Barbara Kazdan, Scott E. Pike and Kavita Mistry

InFOCUS

APHA November 2000, Boston, Massachusetts
Comprehensive primary eye care is still not accessible for over one billion people world- wide. Although virtually no country has ubiquitous access, the problem of unavailable eye care is considerably worse for economically disadvantaged populations. The consequences of poor vision, even when only minor vision correction is required, seriously hamper contributions to societal survival and progress. To remedy this problem, volunteer services from eye care professionals and volunteers from affluent communities have hardly any calculable effect. Few, if any, evaluative studies have been made to determine the benefits of lay volunteers, missionary workers and even well-organized “official” programs such as the Peace Corps with primary eye care efforts. The evidence of care is limited to numbers seen, anecdotal reports, or items (eye glasses, medicine, nutritional supplements, etc.) dispensed.

Despite concern and well-meaning intentions, primary eye care practitioners cannot and will not be able to handle the vast number in need of eye care, which includes almost 400,000,000 children. Unnecessary blindness, let alone the need for correction of refractive errors are increasing problems for much of the world’s population. Even in the light of widespread volunteer activities by many eye care professionals, international agencies, and programs dedicated to a resolution of unnecessary blindness and reduced vision is the need increasing, mainly as a consequence of increased life expectancy and population growth. Adherence to a medical model of care, rather than encouraging public health practice imposes limitations on improved access. Here is a typical scenario:

A new paradigm is needed to expand primary eye care beyond the “medical model,” increasing access, but not compromising quality of care. Community-based Vision Stations can provide sustained primary eye care when eye doctors are unavailable or in short supply.

The World Health Organization through its current global initiative, “Vision 2020,” Calls for “elimination of visual impairment due to refractive error and low vision.” The first three strategies to reach this goal are:

• Create awareness and demand for refractive services through community-based services, specifically primary eye care and school screening;
• Develop accessible refractive services for individuals with significant refractive errors; and
• Ensure that optical services provide affordable spectacles.

Primary eye care represents the patient’s first encounter with ophthalmic care. During this encounter, a trained community health worker can measure visual acuity, screen for refractive errors and other vision problems, (as well as diseases such as diabetes, tuberculosis, or many other endemic problems) and make referrals to qualified professionals or clinics. Early detection of eye and other health problems, with appropriate referrals to medical care, can significantly improve the health of large populations. Vision Stations are limited primary eye care practices that can provide this. To establish a Vision Station, local community health promoters are trained to:

• Measure visual acuities and determine refractive errors using appropriate technology for the location (e.g., focometry where the population is economically disadvantaged; no electricity; etc.);
• Dispense eyeglasses;
• Obtain individual and family eye and general health histories;
• Assess nutritional and general health status;
• Provide preventive eye and general health education;
• To recognize presbyopia, eye infections, dry eye inflammation, trauma and cataract;
• Treat selected eye conditions according to specified protocols;
• Refer patients to appropriate medical resources;
• Maintain clinical and business records; and
• Use local media to market and promote eye care services.

Each Vision Station requires a Primary Eye Care start-up kit which includes:

• A FOCOMETER with clock target and operating instructions;
• Eye charts and pinhole occluder;
• A program manual including diagnostic and treatment protocols;
• Patient record forms; and
• Preventive eye health education materials (language specific).

To meet local needs, start-up supplies of the following items are usually added:

• Assorted spectacle lenses;
• Assorted spectacle frames;
• A tripod;
• Ophthalmic antibiotics; and
• Vitamin A capsules (therapeutic doses).

Spectacle lenses and frames are designed to be able to assemble the correct prescription from the available stock. Unusual prescriptions may need to be obtained from outside the village. Each standard Vision Station serves about 10,000 people, allowing an “economy of scale” adequate to maintain supplies. Eyeglasses are sold for affordable prices, based on research by InFOCUS, an international primary care development organization, ranging from $3 to $11 in very poor and remote communities. The cost of Instant Eyeglasses, described above, is currently about $7 per pair and could easily be afforded in most places around the world. Sustainability of the Vision Station may be enhanced with a profit generated from spectacle sales.

InFOCUS (Interprofessional Fostering of Ophthalmic Care for Underserved Sectors) through its Center for Primary Eye Care Development based in Houston, Texas, has helped establish Vision Stations in the United States, as well as in several developing countries.

For more information about this model, including training recommendations contact InFOCUS.