Comprehensive Eye Care in the Community

R. Meenakshi Sundaram
Senior Manager Outreach
Aravind Eye Care System
Tel: 91-452-4356100, 172
Fax: 01-452-2530984

A screening eye camp is a more comprehensive activity than an outreach surgery approaches in terms of mobilization of resources, optimum utilization of manpower and other resources, quality control, cost effectiveness etc. In India, surgery in eye camp locations Cataract surgeries can be performed in district hospitals or any specialty hospitals where the basic facilities are available and the norms developed by the government are to be followed. In countries such as Nepal, Afghanistan and a few African nations, where accessibility is the main barrier in conducting eye camps, they focus on conducting outreach programmes.

In general, screening eye camps mainly benefit the cataract population. A sizable population is also visually impaired due to other major eye problems such as:

  • Refractive errors
  • Glaucoma
  • Retina-vitreous
  • Diabetic retinopathy
  • Corneal opacity
  • Corneal ulcer
  • Orbit problems
  • Trachoma
  • Onchocerciasis
  • Congenital eye problems
  • Amblyopia
In screening eye camps, cataract patients are identified and they are either taken to the base hospital or referred to the base hospital for surgery. It becomes a little difficult to focus on other eye problems due to:
  • Shortage of manpower
  • Shortage of resources
  • Shortage of professionals
  • Lack of facilities for refraction
  • Preset strategy to serve mainly the cataract population
Many eye care service organizations are unaware of the magnitude of other eye problems in their service area. Over the decades, every service provider has been motivated to reduce the backlog of cataract through nationwide target setting and financial assistance for government hospitals and NGOs.

In particular, the Lions Sight First grant in aid scheme was launched by Lions Clubs International Foundation in 1991 and every Lions club and Lions eye hospital was encouraged to increase its volume of cataract surgery.

The Government of India introduced the grant in aid scheme through the National Program for Control of Blindness (NPCB) with financial assistance from the World Bank in 1994. A well structured target process was initiated and every NGO in India performed a tremendous volume of cataract surgeries. As a result, the prevalence of blindness (Visual acuity <6/60) in India has reduced from 1.49% in 1986-1989 to 1.1% in 2001-2002.

The following table shows the impact of the World Bank Financial Assistance Scheme during the period from 1994 to 1999 in India. It is important to note that the prevalence of blindness due to problems other than cataract has increased rapidly due to the emphasis placed on cataract over other problems.

An estimation of Refractive Errors, Diabetic Retinopathy, and Glaucoma in a population of one million is:

Comprehensive Eye Care by Aravind Eye Hospitals:
A routine camp begins at 8.00 am and ends at 2.00 pm. Camp organizers play an important role and oversee all activities right from crowd management to the transportation of patients in need of cataract surgery to the base hospital. The organizer also works with the medical team to ensure that the required medicines, instruments, spectacles grinding sets and frames are transported to the camp site.

The medical team sent to the eye camps comprises of:
  • Camp Organizer
  • Ophthalmologists
  • Paramedical Staff
  • Patient Counselors
  • Opticians
  • Van driver
In a small camp 200-300 patients will be screened, a medium sized camp will see around 500 patients and a large camp will draw over 800 patients.

As a general rule of thumb, organizers expect operable cataract numbers to be 25% of their out patient load. Depending on the size of the camp the requisite number of medical personnel are assigned. In an Aravind camp 1 doctor with 3 paramedics, 1 counselor and 2 opticians screen 200 patients. The success of each camp depends on a large extent on community participation, effective publicity and the experience of the camp organizer.

Over the years the camps conducted by Aravind have gradually adopted a more comprehensive approach. Today they not only screen for cataract but for other common eye diseases as well. At these camps patients detected with conditions such as glaucoma, diabetic retinopathy, etc. are provided with a referral ID card that they are to carry with them to the base hospital for further medical intervention and management.

The screening process at an eye camp is carried out in a step-by-step manner as follows:

The camp sponsor is requested to provide volunteers to record the patient name and address details. Basic information like the patient name and address, date and location of camp and outpatient number are recorded. The hospital provides all kind of records, registers and other supplies for both clinical and non clinical areas. The records used in this stage are:
  • Identity card (handed over to the patient for follow up visits)
  • Out patient card (patient is to carry this card till the final examination)
  • Out patient register (kept in the hospital for further reference)
Step 1: Visual Acuity Test
All the patients are directed from registration to the paramedics to measure the visual acuity in both eyes. Junior paramedical staffs measure visual acuity with the help of the Sellens chart. A distance of six meters is maintained between the patient and the chart. The visual acuity is recorded in the case sheet. Then they are directed to preliminary examination by the Doctors.

Step 2: Preliminary Examination
The case history is recorded. Doctors use torch light and direct ophthalmoscope to diagnose ocular defects and refer for intraocular pressure and lacrimal duct test. The patients are directed to Refraction based on the need.

Step 3: Duct and Intraocular Pressure Examination
A well trained paramedical staff is posted to measure the intraocular pressure and lacrimal passage test which is recorded in the case sheet. All supplies such as schiotz tonometer, syringe, needles, drops etc. from the hospital are kept on hand. It is essential to measure the pressure to identify glaucoma symptoms and a duct free condition will help in the performance of cataract surgery. Patients with a block in lacrimal passage will be examined by the doctors and referred for medication or other procedure like DCT, DCR based on the findings.

Step 4: Refraction
A well trained optometrist or refractionists are posted to perform refraction. This stage is usually not performed by many hospitals in screening locations mainly due to lack of optometrists and inadequate dark room facilities. Aravind uses portable steel rod cubicles to set up dark rooms in the screening site with necessary supplies like trial set, retinoscope etc. Dilation is also done in this stage if necessary.

Step 5: Final Examination
A senior doctor is posted to do the final examination. They take a decision based on the clinical examinations described in the previous steps. They also dilate the eyes and examine the fundus if necessary.

Probabilities are:
  • cataract (visual acuity <6/60) advised for surgery (spot admission)
  • cataract with systemic problems - advised for surgery based on physicians opinion and admission with an attendant
  • immature cataract/early cataract advised for examination after an interval
  • irritation, dry eyes, itching, etc. - advised medication (free medicines are not offered)
  • refractive errors- spectacles advised (available in camp)
  • specialty problems- referred to specialty clinics in base hospitals for further medical intervention and management
Step 6: Counselling
Patient counselors are similar to paramedical staff but possess more advocacy and less clinical skills. These counsellors are young girls who have completed their school higher secondary education in schools They are imparted basic clinical knowledge during their training at the base hospital. They develop their communication skills and play a major role in patients satisfaction. They have a very high level of accountability in terms of surgery acceptance rate, specialty problem cases referral acceptance rate and surgery follow up acceptance rate in every camp.

Based on the findings and advise by the doctors, the counselor explains the operable condition of cataract and convinces the patient to opt for admission and surgery at base hospital. Since all the selected patients are transported to the base hospital as a group, attendants to accompany the patients are discouraged. Attendants are permitted when the patient has only one functioning eye or has difficulty in walking alone. The counselors also explain the date of surgery; discharge details to the patient and attendant so that the relative or attendant can pick up the patients when they are sent back to the same camp site venue.

If the patient has cataract in operable condition but with some systemic problems like hyper tension, severe diabetes, cardiac problems, asthmatic complaints, ulcers in the body, they are advised to visit their physician for his opinion. They can come to the base hospital for surgery with an attendant. It helps avoid risk at any point of time.

If the patient has developed immature cataract, they are advised to come to base hospital after a few months and then opt for cataract surgery. If they are unable to pay either for their travel or surgery, they can attend camps in the vicinity for their operation.

For patients with specialty problems like glaucoma, diabetic retinopathy, based on the clinical condition, they are advised to visit the base hospital directly to examine their eyes in specialty clinics for appropriate management. Clarifications of the problems, consequences and importance of further examination are explained clearly. All the patients are issued a referral card and advised to visit the base hospital on a specific date to meet a counselor for guidance and necessary help. The counselor records the referral details and monitors the patients arrival - as the purpose of early detection is the goal of comprehensive eye care services.

If the patient is advised to wear spectacles, they are directed to spectacles dispensing service area at the camp site itself.

Step 7: Optical Dispensing Services
A mobile optical service is a part of the medical team for a camp of any size. Around 10% of the outpatients who attend the camp need to wear spectacles. On-the-site delivery of spectacles motivate the patients to buy them at the camp site. The acceptance rate is around 84%.

The camp publicity hand bill has been standardized to communicate the conduct of a camp and facilities offered. Camp sponsors include details such as the date, venue, and a brief note about common eye diseases, availability of spectacles that will be delivered on the spot at an affordable cost.

Whenever the patient is advised to wear spectacles or change the current power glasses, they are directed to this section and patients are allowed to choose the frames. The optical sales staff and technician have a stock of frames and lenses depending on the expected number of outpatients along with other necessary equipments. The sales staff handles the order and delivery. The technician takes care of selection of the lens with exact power, to mark, finish and fit into the frames.

The process takes 15 minutes following which the patients try them out and get any problems rectified immediately. This service is generally well appreciated by the patients and the camp sponsor.

Step 8: BP Recording for Cataract Patients
The patients who are advised for cataract surgery undergo a BP check before admission. It is recorded in the case sheet.

Step 9: Admission of Cataract Patients and Transportation to Base Hospital
The camp organizer helps the patient counselor attach a couple of more records along with the OP card for all the cataract patients. The records maintained in this stage are:
  • In patients register (to record patients complete address, age, gender and eye to be operated)
  • In patient card (to record all clinical information especially in the Operation Theater)
  • Discharge summary (patient and camp details, set of post operative instructions and medication particulars. It also has the details of the date and venue of follow up after 30 days of surgery)
Consent form (patients are counseled about all aspects of the surgery following they indicate their consent by signing the form (thumb impression is also acceptable).

The sponsors provide lunch as patients would reach the base hospital only in the evening. The sponsors and camp organizers jointly arrange buses to transport all the patients to the base hospital.

The patient counselors generate all the relevant information and hand it over to the outreach department. They also monitor the arrival of referred patients in a week and record the details.

In 2005, Aravind-Madurai conducted 364 screening camps and 132,366 out patients were screened. The ratio of eye problems diagnosed in the camps are:

On an average 71% of the outpatients who attended the camps had some kind of eye problem.
5.6% of the outpatients had specialty problems.
51% of the specialty cases were referred to base hospital for further medical intervention and management
In a week, 69% of acceptance for the referred cases has been recorded

Efforts to create awareness in the community to attract more patients with eye defects and increase the referral acceptance rate to restore their vision is an ongoing endeavor.