Int Health 2014; 6: 158–159 doi:10.1093/inthealth/ihu049 Advance Access publication 24 July 2014

COMMENTARY

Vision 2020: moving beyond blindness Susan Lewallena,*, Van Lansinghb and R. D. Thulasirajc a b

Kilimanjaro Centre for Community Ophthalmology, Department of Ophthalmology, University of Cape Town, South Africa; International Agency for Prevention of Blindness/Vision 2020, Weston, Florida, USA; cLions Aravind Institute for Community Ophthalmology, Madurai, India

Received 16 May 2014; revised 24 June 2014; accepted 27 June 2014 Most industrialized countries and many emerging economies have chosen to define ‘blindness’ at a visual acuity above that which WHO uses. This reflects the increasing visual demands of modern society for tasks such as driving or using cell phones. Meeting these demands will require more highly skilled health workers using more sophisticated equipment than has generally been considered sufficient for primary eye care. Keywords: Blindness, Eye care, Vision 2020, Visual acuity

VISION 2020: The Right to Sight is an initiative developed and launched in 1999 by WHO and the International Agency for the Prevention of Blindness, the latter being a coalition of NGOs, academic centres and professional bodies dedicated to improving vision. The goal of the VISION 2020 initiative was ‘elimination of avoidable blindness’ by the year 2020. ‘Blindness’ is defined by WHO and the VISION 2020 initiative as visual acuity (VA) of less than 3/60 (20/400 or 0.05); this translates approximately to the ability to count fingers accurately at 3 meters. While this level of vision allows mobility, pushing a plow and attending to some basic activities of daily living, it does not allow one to recognize a face across the road, drive or see text and keys on a cell phone, among other activities. In many low- and middle-income countries, these latter activities are of increasing importance. In Latin America, for example, vehicle ownership increased by 50% in the years 2002–2007 and it continues to increase.1 About 84% of Latin American households subscribe to a mobile phone service, indicating wide usage of these.2 Similarly, in India, there are over 875 million mobile phone users, roughly 75% of the population, with similar proportions in the rest of Asia.3 Reflecting on these facts, it is worth noting that both in Latin America and India blindness is usually defined as visual acuity of less than 6/60 (20/200 or 0.10), roughly the ability to count fingers at 6 meters rather than 3. The question to ask, in view of changing expectations, is: shouldn’t we all be striving to eliminate visual impairment well before blindness at either definition sets in? Considering the main causes of blindness, this is entirely possible and it happens all the time in the industrialized world. Cataract, for example, still the main cause of vision loss in subSaharan Africa, Latin America, and Asia4 can be managed by wellestablished surgical techniques. In the past few decades there

have been some major changes in technologies available to eye surgeons, even in remote places. Small incision techniques and inexpensive, more readily available intra ocular lenses make it feasible to operate on cataract long before it has progressed to the stage of blindness. This is important in view of changing needs. Of course, much work remains to be done in ensuring that the quality of surgery is optimal, that patient satisfaction is at the forefront and that marginalized populations have access to services, but in view of the technology, shouldn’t we move the goal line and encourage operations on eyes with cataract earlier, before blindness occurs? In India, hospital data indicate that half of the patients getting cataract surgery in the first eye, do so with visual acuity better than 6/60. If we want to avoid visual impairment (VA ,6/18 [20/60 or 0.33]) and not just blindness, some of our suppositions regarding human resource needs may need to be reconsidered. The skills and equipment required to correctly diagnose cataract before it becomes blinding and to identify posterior segment diseases, such as diabetic retinopathy and glaucoma, are beyond what can be done with a simple torchlight by a general primary health worker. Uncorrected refractive error is another significant cause of visual impairment5 and it also requires some technical skills to manage properly. Are we training the right mix of people and in the required numbers to meet these needs? In much of Asia and Latin America ‘primary eye care’ is likely to be delivered by medical personnel who specialize in eye care, but in Africa, in the name of ‘integration’ of eye services into the general health system there has been a strong push to depend on general primary health workers to provide the front line for eye care. This cadre is also responsible for fulfilling a myriad of other primary healthcare duties largely related to women and children. It is critical to determine what providers of primary eye care (whoever they

# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].

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*Corresponding author: Tel: +27 (0)21 4047601; E-mail: [email protected]

International Health

be) are realistically capable of in terms of examination and diagnosis of eye conditions. This becomes more important as we move the goal from detecting only the most advanced or severe stages of disease to identifying and offering treatment to people before blindness is manifest. The term ‘eye health’ has been adopted by many to emphasize the fact that our field is not just about dealing with blindness after all. We need to deal with visual loss at whatever level is meaningful in the population. We need to keep in mind always that the function of the eye is to provide sight: eye health must continue to prioritize conditions that impair vision; let’s just not wait until they become blinding to do so.

Competing interests: None declared.

Authors’ contributions: SL, VL and RDT conceived, wrote and revised the manuscript. All authors read and approved the final manuscript. SL is the guarantor of the paper.

4 Stevens GA, White RA, Flaxman SR et al. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990– 2010. Ophthalmology 2013;120:2377–84.

Funding: None.

5 Bourne RA, Stevens GA, White RA et al. Causes of vision loss worldwide, 1990–2010: a systematic analysis. Lancet Glob Health 2013;1:e339–49.

Ethical approval: Not required.

References 1 Becerra JM, Reis RS, Frank LD et al. Transport and health: a look at three Latin American cities. Cad Suade Publica 2013;29:654–66. 2 The World Bank. Latin America leads global mobile growth. http://www. worldbank.org/en/news/feature/2012/07/18/america-latina-telefonoscelulares [accessed 6 May 2014].

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3 Telecom Regulatory Authority of India. Highlights on Telecom subscription data as on 31st October, 2013. http://trai.gov.in/WriteRead Data/WhatsNew/Documents/PR-TSD-Oct--13.pdf [accessed 30 June 2014].

Vision 2020: moving beyond blindness.

Most industrialized countries and many emerging economies have chosen to define 'blindness' at a visual acuity above that which WHO uses. This reflect...
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