National Vision 2020 Plan for the prevention of blindness in Grenada

DRAFTED BY: Workshop of Stakeholders.

DATE: 8^th August 2008

VENUE: Conference Room, Ministry of Education – Grenada.

 

1. INTRODUCTION

People and Population 2008:

Grenada Demographic Profile 2008

Indicator	2008
Population (thousands)	107,381
Population over 50	21,276
Population between 5-15	27,308
Population attending the school 5-18	23,306
Total school population in grade 5	2,213
Number of new-born per year	1,450

2. BLINDNESS

Blindness Worldwide

 In 2006 WHO estimated that more than 161 million people globally were visually impaired due to eye diseases, 124 million of whom had low vision and 37 million were blind, an additional 153 million people have visual impairment due to uncorrected refractive errors. 

 Two thirds of these visually impaired cases might have been cured or prevented through increased awareness, or with relatively simple treatments and surgical interventions. 

Most persons with a visual handicap are found in developing countries, this is mainly due to the lack of access to adequate services.

Blindness and low vision are a public health problem throughout the world, and support and rehabilitation are a burden to the economic conditions of families and eventually to the national economy. This is why WHO, together with worldwide known NGOs, has launched the VISION 2020 worldwide program. This program, that brings together Governments, WHO, International and local NGOs, as well as Associations of Professionals in Eye Care, aims to reduce preventable and curable blindness and visual impairment.

Blindness in the  Caribbean:

The prevalence of Blindness in the Caribbean is estimated in 0,5% of the population.

The Barbados Eye Studies demonstrated the following causes of incident blindness:

Cataract: 52%

Cataract and Open Angle Glaucoma: 9%

Open Angle Glaucoma alone: 10%

Diabetic Retinopathy: 10%

Others: 19%

 Vision 2020 was officially launched in Trinidad & Tobago in July 2000. The four priorities in the initiative defined for the region are:

·        Cataract, primary cause of worldwide blindness

·        Glaucoma, most common in black population

·        Diabetic Retinopathy

·        Child Blindness and major refraction problems

  

Blindness in Grenada 

 

Country	Population	Blindness @ .05%	Avoidable Blindness @ 80%	Incurably Blind @ 20%
Grenada	107,381	537	430	107

 

3. SITUATION OF EYE HEALTH AND EYE CARE SERVICES

 

There is one  Public Hospital in Grenada which is located in St George’s. A new Hospital is being built nearby but it will have no Eye Department. There are no other Hospitals on island with Eye Units.  In addition there are six Health Centres around the country which are staffed by District Nurses.  There are (2) Ophthalmologists in the country with only one serving the Public Sector. The Ophthalmologist in the Public Sector is supported by a full-time Junior Doctor. There is one (1) Optometrist as well as a Registered Nurse trained in Adjustment to Blindness Techniques. District nurses also have some basic eye training

 There is one (1) Eye Operating Theatre. There are twelve (12) available beds for eye patients. The OPD is suitably equipped, but it has no functioning laser. The service has access to a Digital Fundus Camera, but no one is trained to operate the system.  

 

4.  PLAN OF ACTION 2008 -2012

 

Aim:  To reduce the causes of preventable blindness in Grenada.

 The approach to implementing the established activity areas of VISION 2020 are:

• Disease Control;
• Human Resource Development (HRD); and
• Infrastructure and Technologies.

DISEASE CONTROL

Table Criteria for identification of target Diseases in the Caribbean

Disease	Importance	Effectiveness of intervention	Priority Ranking
Cataract	+++++	++++	1
Glaucoma	+++++	+	4
Diabetic Retinopathy	+++	++	3
Refractive	++	+++	2
Childhood Blindness	++	++	5

 

The total number of cataract surgeries performed in the year 2007 was 114. In order to significantly address the problem of blindness and severe visual impairment due to cataract, a cataract surgical rate of 2000 per million per year is required.

 

 

Country	Population	Number of cataract  Surgeries Year 2007	CSR 2000 Million x year
Grenada	107,381	114	215

 General barriers to Eye Care include:

·        Cost can be considered a barrier, albeit not a significant one. The cost incurred by patients for cataract surgery is $200.00 EC. However self identified indigent patients are provided the service free of cost 

·        Cultural barriers, for example fear of surgery exist but this is not considered a major issue

·        Accessibility and compliance remain issues for concern in preventing blindness

·        Waiting list for consultation

·        Waiting list for surgery is related to

a.      Lack of sufficient number of cataract surgery sets (instruments); cataract kits (consumables)  and linen

b.      Inadequate training of Nurses in Operating Theatre

 

·        Inadequate numbers of Nurses and Auxiliary Personnel  in the Public Eye Care System

·        Improper selection processes for Nurses and high levels of rotation of trained Nursing Personnel

·        Non-optimal systems and procedures for patient processing in the Outpatient Clinic

·        The unfavorable aesthetic/ lack of comfort in the Clinic waiting area as well as long waiting times

 

Aim:  Elimination of Cataract Blindness

 

Objectives:

·        To establish an effective public awareness program on various levels

a.       At the community level there needs to be education on the nature and availability of eye care and also essential information about diseases that may lead to blindness

b.      At the patient level; they and their families should be educated about their eye disease and the subsequent implications for their vision

·        To increase patient compliance for referrals

·        To increase compliance with  subsequent treatment whether medical or surgical

·        To re-establish a regular and reliable Outreach Program that includes screening education and referral  to patients in their community

·        To have  a waiting period of no more than a month for consultation

·        To have a  waiting list of no more than 3 months for cataract surgery

·        To establish or create more favorable conditions for outpatient care  (to include infrastructure, processes and amenities)

·        Services affordable for all people

·      Monitor and improve visual outcomes to WHO Standards

•  
  1. Percentage of post-operative patients with IOL implants (should be at least 90%)
  2.  Percentage of persons with post-operative best corrected visual acuities of 20/200 or less (should be less than 10%)
  3. Complication rate (should be less 10% including 5% related to  vitreous loss)

 

Indicators:

1.      National Cataract Surgical Rates – CSR (i.e. number of cataract operations per million population per year).

 

National targets of Cataract Operations per year

 

Year	2007	2013	2020
CSR	1062 x million	2000 x million	3000 x million
Number of operations per year	114	215*	322*

**The numbers shall be adjusted to the population in the years 2013 and 2020

 

In 2007 there were 2122 school children screened through the National Vision Screening Program. 

Aim: To reduce visual impairment due to uncorrected Refractive Errors.

Objectives:

·        To review the current protocol for screening and referrals

a.      Organise a National Workshop to review the Protocol and Guidelines

b.     Implement a Refresher Course for Screeners 

·        To provide good quality low cost spectacles to children and adults who cannot afford to purchase commercial options.

a.       Ensure access to an affordable optical service (spectacles laboratory and Optometrist/Refractionist).

 

Indicators:

 

·        New Protocol and Guidelines developed

·        Courses provided for the Primary Eye Care Personnel 

·        Maintaining or increasing the current coverage

 

 

 Aim: To initiate low vision care and strengthen rehabilitation and education in Grenada.

Objectives:

·        To establish Low Vision Services in Grenada.

1. Identify at least 1 National Provider of Low Vision Services.
2. Give a short Training Course to the local professional who will provide services.
3. Give support with basic equipment and LV Aids.
4. Promote the utilization of LV Services by Ophthalmologists through a referral system 

·        To strengthen the Education and Rehabilitation Services for children and adults who are  blind

1. Strengthen the link between LV Services and: Inclusive Education and Adjustment to Blindness Services (AtBS) for adults.
2.  Provide awareness training to: Adjustment to Blindness Instructors/Counsellors and other Community-based Rehabilitation (CBR) Workers on LV.

 Indicators

·        Establishment of basic LV Services by the end of the period.

·         Inclusion of LV Modules in Training Courses for Special Education Teachers and Adjustment to Blindness Instructors/Counsellors.

 

 

 Situation

 There is one Neonatal Care Unit, in 2007 with one baby being treated for ROP 

Aim:    To reduce avoidable causes of blindness in children

 

Objectives:

 

·        To establish an appropriate program for preventing avoidable blindness from Retinopathy of Prematurity.

·        Training of Ophthalmologist for screening of ROP.

 

·        To introduce minimal acceptable standards for oxygen monitoring

a.       Personnel trained in oxygen administration  procedures

b.      Availability of proper equipment (e.g. Pulse Oximeter)

c.       Availability of proper Blenders and Heater Humidifiers

d.      Keep oxygen saturation between 88% and 92% and monitor arterial oxygen between 70 and 80 mm Hg

 

• To establish an appropriate program for preventing avoidable Childhood Blindness particularly from Congenital Cataract and Glaucoma, including a Regional Referral System.
•  To establish a Protocol for the referral of Paediatric Cases overseas

·        (Including a MOU between participating Governments)

 

Indicators:

·        Number of babies screened fewer than 1500 gm.

·        Number of babies screened for the detection of Cataract and Congenital Glaucoma

·        A referral system developed and put in place

 

 

 

 

Situation Year 2007:

1                    The basic equipment is in place for the screening of Diabetics.[Digital Camera] (but not for treatment)

2                    No active screening occurs at present.

3                    There is a lack of technical support for machinery.

4                    Diabetic control is generally poor.

5                    There is a Diabetic Association; however, there is inadequate information on the status of Health Education Programmes for Diabetics.

6                    There is no functioning Laser Service.

Aim: To reduce the prevalence of blindness from Diabetic Retinopathy.

Objective:

1.      To establish the clinical and technical infrastructure to treat Diabetic Retinopathy (Laser)

2.      To develop a plan of action to screening Diabetics for Diabetic Retinopathy

Strategies:

1. Train other specialized Doctors (Endocrinologists, etc…) who see diabetic patients in order for them to detect and make referrals to the Ophthalmologist
2. Identify opportunities for adding basic screening methods for Diabetic Retinopathy while performing eye examination for other eye conditions, such as those before and after cataract surgery.
3. Further Training or Refresher Courses for local Ophthalmologists, if necessary.
4. Technical support for instrument maintenance.
5. Establish an Inter-country Referral System, where feasible.
6. Education Programmes for Diabetics

 

 

Situation

The Barbados Eye Studies found that about 7% of the Afro-Caribbean population over 40-84 years has Glaucoma. No national statistics are available.

Ophthalmologists prefer not to carry out glaucoma surgeries because the perception of patients of such surgery is not good – when outcomes do not meet patient expectations it can damage the reputation of the Surgeon.

 

Aim: To reduce avoidable blindness from Glaucoma

 

Limitations

·        Feasibility of the known screening methods to date is low.

Strategies

The major areas of activities are as follows:

·        Identify opportunities for adding basic screening methods for Glaucoma in patients over 35 years while performing eye examination for other eye conditions, such as those before and after cataract surgery.

·        Wherever possible, ensure that at least the basic equipment and medication are available in the services

·        Train local Surgeons in Glaucoma Surgery (if applicable).

·        Community Education in regard to risk factors, people with risk factors (over 40 years, family history) should look for en eye exam (optic disc assessment plus IOP).

·        Utilise low cost Timolol and generic drugs for those in need of treatment.

Situation

Numbers of new Ophthalmologists that remain in practice are: 2

Numbers of Eye Surgeons is 2.

Number of Optometrist is 1.

There are no Ophthalmic Nurses,

There are no Primary Health Care (PHC) Workers trained in PEC.

There is no an expert in Low Vision 

Objectives

1. To train at least  one additional Ophthalmologist by 2013
2. Increase the Surgical productivity per Ophthalmologist

Target cataract surgeries done per Ophthalmologist

Year	2007	2013
Cataract Surgeon /Ophthalmologist	48	100

Strategy

• Overcoming existing constrains in their work
• Utilization of Allied Health Personal
• Improve supply of materials for cataract surgery

• Training in Surgery and Sub-specialities
• Implementation of a Surgery Quality Program 
• Training in Community Ophthalmology

Objective:

 

Re establish an Allied Health Personnel Program in Ophthalmology (Refraction Technician and Ophthalmic Technicians).

 

Target OT per population	2013	2020
Grenada	1:50 000	1:25 000
Number	2	4

Strategies

 

·        Identify Training Centres; candidates; and financial resources

·        Identify a Training Centre to train OT or Ophthalmic Nurses (Dominica?).

·        OT can be trained initially to make simple tasks at the primary level that can be upgraded in further training up to a Refractionist level and to perform special tasks at selected Centres according to the respective Matriculation Standards.

·        Nurses could be trained as Ophthalmic Nurses.

 

Optometrists & Refractionists

Situation 

–         There is one Optometrist working in Grenada 

Objective:

 

Target Optometrist  x population	2008	2013
Grenada	1:100 000	1:50 000
Number	1	2

 

·        To train at least one (1) Optometrist and (2) Refraction Technicians)  for the Public Sector by 2013

 

Primary Health Personal

Objective:

·      To train Primary Health Care Personnel in Primary Eye Care at all the Health Centres.

There is one Out-Patient Unit and one Private Office and one Public and one Private Operating Theatre.

Aim: To provide the necessary infrastructure, equipment and supplies to the eye care activities in the country.

Strategies

1. Identify barriers in obtaining equipment, surgical kits.
2. Development of the Ophthalmic Unit of the General Hospital in Grenada
3. Provision of ophthalmic surgical consumables and equipment.

 

– The National Committee and a Focal Person for the National Committee for the Prevention of Blindness (NCPB) to be appointed-recognised by the Government.

– The NCPB to meet every 6 months

– MOH to achieve regular collection, collation and submission of Vision 2020-related data.

 

BIBLIOGRAPHY:

 

1. United Nations: Population Division: World Population Prospects: The 2006 Revision Population Database.
2. Pan American Health Organization: Technology and Health Services Delivery: Strategic Plan for Vision 2020: Caribbean Region. PAHO/CAR/3.1/02.06
3. Pan American Health Organization: Technology and Health Services Delivery: Eye Diseases in People 40-84. The Barbados Eye Studies: A Summary Report. THS/OS/06/8
4. CCB & PAHO Trip Reports and NGO Collaborating Group Minutes 2002- 2008