Summer School in International Health Causes of blindness
University of Copenhagen, August 2010 • Developed • Developing
countries countries
Eye
y diseases • Age-related Macula
Degeneration (AMD)
•
•
Cataract
Trachoma
• Glaucoma • Xerophthalmia
Thomas Storr-Paulsen, MD • Diabetes • Onchocerciasis
Dept. of Ophthalmology, • 85% of all blindness • Trauma
Odense University Hospital • 75% of all blindness
Trachoma - Epidemiology Trachoma - Patogenesis
• Infectious agent: Chlamydia Trachomatis • The acute infection is limited to the
type A, B, Ba og C conjunctiva and is often selflimiting
• Transmitted via secretion from eyes or • Re-infections cause conjunctival scarring
faeces i malpositioned
• Scarring
S l iti d eyelashes
l h
• The infectious reservoir is in children (trichiasis)
below 2-3 years of age • Trichiasis Corneal scarring
• Trachomatous blindness is 2-3 x more • Endstage after 15-20 years blindness.
frequent in women
Vision 2020 and Trachoma Surgery for trichiasis
• Regular surgical sessions held at fixed
• GET2020: sites
Targeting Global Elimination of Trachoma
as a cause off blindness
bli d by
b 2020 • P
Periodic
i di outreach
t h sessions
i h
held
ld iin
trachoma-endemic communities
• SAFE strategy
• Ensure effective case finding
1
Antibiotics Facial cleanliness
• Against Chlamydia Trachomatis
• Health education
• Cures the eyeinfection and removes the
about trachoma
infectious reservoir in the respiratory and
G I tract
G.I.
• Tbl. Azithromycin p.o. 1000 mg or 20
mg/kg as a single dose
• Eye ointment tetracycline 1% x 2 daily for
6 weeks
Environmental improvement SAFE
Strategy
• Inadequate disposal of waste
• Reduce household crowding
• Reduce breeding sites for flies
• Encourage use of latrines
• Identify strategic partners
Xerophthalmia - epidemiology Xerophthalmia - Epidemiology
• The most frequent cause of childhood • Worsened by concurrent infections, eg.
blindness Measles or diarrhoea
• 350.000
350 000 bli
blind
d children
hild per year • 60
60-80%
80% d
does nott survive
i ththe ffollowing
ll i ffew
years
• Most frequent from age 1 to 3 years
• 250 mio. children in preschool age has
vitamin A deficiency
2
Xerophthalmia - Pathogenesis Xerophthalmia - Pathogenesis
• Vitamin A deficiency due to:
– Reduced intake • Reduced secretion of mucin from goblet
– Reduced absorption, eg. diarrhoea, cells
malnutrition
– Increased demand, eg. during infections
(measles) • Keratinization of epithelia in conjunctivae,
cornea, respiratory and GI tracts
Xerophthalmia - Symptoms Dietary vitamin A
• Eye symptoms and signs: • Encourage exclusive breastfeeding the
– Night blindness
first 6 months of life
– Grey-white plaques on bulbar conjunctiva (Bitots
spots)
– Unclear cornea • W
Weaning
i with
ith mashed
h d mango, papaya,
– Corneal oedema and ulcers
carrots.
– Retinal damage
• Other symptoms:
– Dry skin • Give children ¼ -½ papaya or mango daily
– Increased susceptibility to infections • Egg, milk, liver, red palmoil, spinach
Health education and
Cataract
xerophthalmia
• Target group is children 6-36 months of age
• Reduced vision due to an opaque lens
• Identify children at risk for vitamin A deficiency
• Curative surgical treament available
• Encourage sufficient dietary vitamin A intake in
children • Good visual prognosis after surgery
• Early intervention, nightblindness is a red flag • Responsible for 48 % of global blindness, ie 18
mio blind
3
Causes of cataract Diagnosis and treatment
• Age-related opacities of the lens • Reduced vision, blinding by strong lights
• Exposition to UV-light
• M l t iti
Malnutrition • On a dilated pupil dark opacities are seen
• Chronic diarrhoea against the red reflex
• Trauma
• Surgical removal of the unclear lens and
implantation of an artificial lens
Complications to surgery Strategies against cataract
• Outreach programme
• Sight threatening complications: retinal
d t h
detachment,t infection,
i f ti h
haemorrhage
h • Mobile eye units
(1-2%)
• Referral to public and private clinics
• Secondary cataract (30% after 5 years)
Barriers to cataract surgery Promoting Cataract Surgery
• Hidden costs • Locate and diagnose patients
– Transport
– Childcare • Obtain informed consent from patient
– Accomodation
– Unable to leave family or work responsibilities
• Clear communication with eye clinic
• The stigma of poor vision
• Plans for accomodation, food and
transportation
• Fear of surgery
4
Onchocerciasis (River blindness) Onchocerciasis - Pathogenesis
Epidemiology
• Endemic in 37 countries in Africa south of • The parasite Onchocerca Volvolus
Sahara, Yemen and South America
• Transmitted by the blackfly – breeding in
• 270.000
270 000 bli
blind
d oxygenated
t d fresh
f h watert
• 18 million infected and 125 million at risk • Female up to 50 cm long, can live up to 15
of infection years in human skin noduli,
onchocercomas
Onchocerciasis - Pathogenesis Symptoms and Signs
• Producing microfilariae (0,3 mm), up to
150 million in infested individuals • Intense itching, white atrophic skinlesions
• Infiltrate
I filt t skin
ki and
d eyes • Sclerosing keratitis with pannus formation
• Strong immune reaction to dead • Iritis, chorioretinitis, optic neuritis
microfilariae
• Visual impairment or blindness
Onchocerciasis Control
Diagnosis
Programme
• Onchocerciasis endemic in the area? • Vector control
• Visible nodules,
nodules itchiness,
itchiness white skin lesions
• 1.235.000 km2 and 50.000 km stretches of
river in 1988-2003 in West Africa
• Microscopy of skinsnips in saltwater
• Slitlamp examination • Application of insecticide via aircraft
5
Loa Loa
• 5-10 cm long worm, travelling in the human body
• Can be visible under the conjunctiva
• Ivermectin contraindicated
• Excision of the worm or oral dietylkarbamazin International Centre for Eye Health, London School of Hygiene
and Tropical Medicine, www.iceh.org.uk
International Centre for Eye Health, London School of Hygiene
and Tropical Medicine, www.iceh.org.uk
Subconjunctival haemorrhage
Estimates of global blindness
Frick KD and Foster A: The magnitude and cost of global blindness: An
increasing problem that can be alleviated, Am J Ophthalmol 2003;135:471-476
