Community/ Social Ophthalmology - aioseducation

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Social Ophthalology-I 

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Contents 

COMMUNITY / SOCIAL OPHTHALMOLOGY - I 

Demographic and Clinical Predictors of Poor Compliance for Part Time 

Occlusion in Patients with Amblyopia............................................................623 

Dr. Anamika Dwivedi, Dr. Sujata Lakhtakia, Dr. Dwivedi P.C., Dr. Syed Imran 

Knowledge, Attitude, Practice Pattern of Retinopathy of Prematurity Among 

Ophthalmologist and Pediatrician ..................................................................626 

Dr. Khushbu Bhattad, Dr. Anand Partani 

A Survey to Assess the Compliance of Low Vision Aids in Visually 

Challenged Patients..........................................................................................630 

Dr. Sara Jacob, Dr. Giridhar A, Dr. Mahesh G., Dr. Ms. Sreeshma T.S. 

Childhood Visual Impairment in Northern India: Causes and Its Co-Relation- 

.............................................................................................................................634 

Dr. Sunita Mohan 

Cataract Care Services for Children: Barriers Encountered in Rural and 

Backward Regions.............................................................................................639 

Dr. Jayashree Baruah, Dr. Deva Prasad Kar, Dr. Sanjib Buragohain, Dr. Mrinal Modhur 

Borgohain 

Visual Impact of Community Cataract Services by a Tertiary Eye Care Centre 

in Rural Central India ........................................................................................642 

Dr. Ritesh Patidar, Dr. Rahul Shah, Mr. Subramaniam Swami, Dr. Elesh Jain 

Paediatric Low Vision: Magnitude, Interventions, Determinants and 

Compliance.........................................................................................................646 

Dr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, Dr. Sudhir 

Taras 

Retinopathy of Prematurity is A Major Cause of Childhood Blindness in Pune 

Region.................................................................................................................648 

Dr. Kuldeep Dole, Dr. Madan Deshpande, Dr. Sucheta Kshirsagar, Dr. Tanmayi 

Dhamankar 

Assessment of Compliance in Children (0-16 Yrs) using Low Vision Aids....652 

Dr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, Dr. Sudhir 

Taras 

Importance of Medical and Patient Care Audit in Community Ophthalmic 

Outreach Programme........................................................................................654 

Dr. Zawar Swati Vijay, Dr. Mamta Singh 

School Eye Health Screening Programme in Ahmedabad District – ‘Making 

The Invisible Visible’.........................................................................................658 

Dr. Priyanka Gupta, Dr. Pina Rasiklal Soni, Dr. Minal Patel 

615

Community/Social Ophthalmology Free Papers 

COMMUNITY / SOCIAL OPHTHALMOLOGY - I 

Chairman: Dr. Velayutham Veerabahu; Co-Chairman: Dr. Gupta B.N. 

Convenor: Dr. Gursatinder Singh; Moderator: Dr. Subudhi B.N.R. 

Demographic and Clinical Predictors of Poor 

Compliance for Part Time Occlusion in Patients 

with Amblyopia 

Dr. Anamika Dwivedi, Dr. Sujata Lakhtakia, Dr. Dwivedi P.C., Dr. Syed 

Imran 

Amblyopia is one of the most common causes of visual impairment in 

children with varying prevalence depending on the type of population 

studied. Occlusion of the sound eye has been the mainstay of amblyopia 

management but treatment success is largely dependent on compliance. Poor 

compliance not only limits the effectiveness of treatment but also increases 

costs to the patient’s family and health care system. 

We conducted a non-randomized intervention study to assess the role of 

various demographic and clinical factors influencing compliance in patients 

undergoing occlusion therapy for amblyopia. 

MATERIALS AND METHODS 

Patients with unilateral amblyopia attending the Squint and Amblyopia Clinic 

of Ophthalmology department, S.S. Medical College, Rewa between October 

’09 and April’11 were enrolled for the study. After excluding patients with 

any organic cause of decreased visual acuity, history of previous treatment 

for amblyopia and neurological disease, a total of 125 patients with either 

strabismic and/or anisometropic amblyopia between 2 to 17 years were 

selected. 

After a comprehensive ophthalmic and orthopedic examination patients were 

provided with optimal optical correction and advised 6 hrs /day of occlusion. 

Depending on the VA at presentation, amblyopia was classified as mild to 

moderate (VA >20/100) and severe (VA < 20/100) based on the amblyopic eye 

visual acuity. The socioeconomic status of the patient’s family was assessed 

using the Kuppuswamy’s Socioeconomic Status Scale (2007 modification). The 

parents were explained in detail about occlusion therapy and its significance 

in the management of amblyopia. They were then asked to keep an accurate 

record of number of hours of patching done per day in a diary. 

All patients were followed up monthly for 6 months and at each visit ocular 

alignment and BCVA were evaluated and glasses changed if needed. Early 

623

70th AIOC Proceedings, Cochin 2012 

response to treatment was defined as >2 log MAR line improvement in


compliance while early improvement in visual acuity is positively associated 

with compliance. 

Table 1: Clinical and Demographic Data 

Variable Total (%) Poor Compliance (%) 

No. of Patients 110 50(45) 

Sex Male 66(60) 32(48) 

Female 44(40) 18(41) 

Age 2-5 33(30) 4(12) 

6-10 26(23) 9(35) 

11-13 24(22) 14(58) 

14-17 27(25) 23(85) 

Cause of Strabismus 25(23) 12(47) 

Amblyopia 

Anisometropia 44(40) 22(50) 

Strabismus + 41(37) 16(39) 

Anisometropia 

Severity of Mild To 41(37) 13(32) 

Amblyopia Moderate 

Severe 69(63) 37(54) 

Early Response Responders 42(38) 14(33) 

To Treatment Non Responders 68(62) 36(53) 

Socioeconomic Upper 24(22) 9(37) 

Status Upper Middle 31(28) 62(56) 13(42) 24(39) 

Lower Middle 31(28) 11(35) 

Upper Lower 14(13) 24(22) 10(71) 17(71) 

Lower 10(9) 7(70) 

Mothers University 22(20) 6(27) 

Education Higher Education 27(25) 8(30) 

Secondary 24(22) 7(32) 

Education 

Primary Education 20(18) 16(80) 

None 17(15) 13(76) 

Fathers University 35(32) 12(34) 

Education Higher Education 28(25) 9(32) 

Secondary 16(15) 6(37) 

Education 

Primary Education 20(18) 5(75) 

None 11(10) 8(72) 

625


REFERENCES 

1. Searle A, Norman P, Harrad R, Vedhara K. Psychosocial and clinical determinants 

of compliance with occlusion therapy for amblyopic children. Eye. 2002;16:150–5. 

2. Al-Zuhaibi S, Al-Harthi I, Cooymans P, Al-Busaidi A, Al-Farsi Y, Ganesh 

A.Compliance of amblyopic patients with occlusion therapy: A pilot study. Oman J 

Ophthalmol. 2009;2:67-72. 

3. Stewart CE, Moseley MJ, Stephens DA, Fielder AR. Treatment dose-response in 

amblyopia therapy: The Monitored Occlusion Treatment of Amblyopia Study 

(MOTAS). Invest Ophthalmol Vis Sci. 2004;45:3048–54. 

4. Awan M, Proudlock FA, Gottlob I. A randomized controlled trial of unilateral 

strabismic and mixed amblyopia using occlusion dose monitors to record 

compliance. Invest Ophthalmol Vis Sci. 2005;46:1435–9. 

5. Loudon SE, Fronius M, Looman CW, Awan M, Simonsz B, van der Maas PJ et al. 

Predictors and a remedy for noncompliance with amblyopia therapy in children 

measured with the occlusion dose monitor. Invest Ophthalmol Vis Sci. 2006; 47:4393- 

400. 

6. Loudon SE, Simonsz B, Joosse MV, Fronius M, Awan M, Newsham D et al. Electronic 

recording of patching for Amblyopia Study: Predictors for non compliance. Invest 

Ophthalmol Vis Sci. 2004;45: E-abstract 4991. 

7. Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy’s socioeconomic status 

scale-updating for 2007. Indian J Pediatr. 2007;74:1131-2. 

Knowledge, Attitude, Practice Pattern 

of Retinopathy of Prematurity Among 

Ophthalmologist and Pediatrician 

Dr. Khushbu Bhattad, Dr. Anand Partani 

Retinopathy of prematurity is a fibrovascular proliferative disorder affecting 

peripheral retinal vasculature in premature infants. ROP screening is 

recommended in all infants with risk factors, such as low birth weight < 2000 

gm, gestational age < 35weeks, multiple births, eventful postnatal periodoxygenation, 

sepsis, respiratory distress and blood transfusions. 1 

With improving survival of very low birth weight infants, ROP has emerged 

as a significant preventable cause of blindness in India. The initial signs of 

ROP may be detected within few weeks after birth and it progresses rapidly. 

Though ROP can be cured by timely and proper intervention but still in India 

nearly 500 children are estimated to become blind due to ROP every year. 2 It is 

estimated that out of 100 preterm infants in India approx 20-40 develop ROP; 

out of which 3-7 become blind. 3 Thus awareness and practice of ROP screening 

626


guidelines, among pediatricians and ophthalmologist is must to tackle this 

emerging problem. 

Present study is conducted to assess the knowledge, attitude and practice 

patterns (KAP) of pediatricians and ophthalmologist about ROP. 


In this cross-sectional study, responses of KAP questionnaire about ROP was 

obtained and analyzed from 156 ophthalmologist and 122 pediatricians in 

central India from may 09-may 11. 

ROP-KAP questionnaire for paediatrician (Knowledge, Attitude and 

Practice Proforma) 

Name, age/sex, email id- type of practice-government/private. 

1) Are you aware of disease affecting eye relating to premature birth? 

If yes then what it is? ROP or others. 

2) What are the risk factors for ROP? No idea, Low gestational age, 

Weight


6) What are the different stages of ROP? 

7) What are the treatment modalities of ROP? 

8) Is there enough awareness of ROP among medical professionals around 

you? Yes / no. 

RESULTS 

Out of 122 pediatricians-male 86(70%) female 36 (30%). Mean age 43.2yrs. 

28(23%) were in government practice and 94(77%) in private practice. 

106(87%) Pediatricians were aware of ROP and only 16(13%) were not aware of 

disease. 

Risk Factors for ROP 

No idea 28(23%) 

Low gestational age 21(17%) 

Weight


birth, 22(13.8%) don’t have idea about it. 70(45%)ophthalmologist knew about 

stages of ROP. Only 52(33.4%) knew about treatment modalities of ROP. Only 

33(21%) ophthalmologist think that there is enough awareness of ROP among 

medical professionals. 

DISCUSSION 

In our study 87% pediatrician were aware of ROP, 23% has no idea about its 

risk factor, 47.5% don’t have idea of 1st eye test for ROP screening. 45.9% knew 

that timely treatment can prevent blindness. 36.9% give guidance to parents 

for regular ophthalmic check-up in high risk babies. Barriers for referring 

preterm babies are- parents not willing 36%, unaware of referral facility 14.7%, 

too expensive treatment 17.2%, not necessary to screen 32%. 

In a study done by Sathiamohanraj SR, et al 4 on 83 pediatrician in coimbatore-65% 

were aware of ROP, 42%have no idea of risk factors,45.8% have no idea of 

1steye test for ROP screening, 39.8% knew that timely treatment can prevent 

blindness. In a study done by Rani and Jalani5 on 38pediatrician in Hyderabad 

-100% pediatrician are aware of risk factors, Barriers for referring preterm 

babies are-parents not willing 18%, unaware of referral facility 15.8%, too 

expensive treatment 13%. 

In the study done by Kemper et al 6 , in a questionnaire survey of neonatologists 

regarding the barriers for ROP screening, the most commonly reported major 

barrier was the lack of available eye care specialists. This indicates the need 

for postgraduate, undergraduate and in-service training programs for ROP in 

developing eye care work force who can effectively screen ROP. 

Till date according to our search there is no study on KAP of ROP among 

ophthalmologist in India. 

In our study among ophthalmologist 94.2% knew ideal method of screening 

is indirect ophthalmoscope and practiced by 34.6%. only 35% screen high risk 

babies. Only 33.4% have knowledge about recent management. 

The first step in reducing blindness due to ROP is recognizing that the problem 

exists. Our study shows that awareness of ROP is poor among pediatricians. 

Reports from other developing countries like China 7 , Thailand 8 and Vietnam 9 

also show a similar trend. Even decades after randomized clinical trials 

for ROP have been published and discussed in ophthalmic literature; this 

information has not been incorporated into our regular practice. As time 

is a crucial parameter in ROP screening, the IAP along with the All India 

Ophthalmological Society (AIOS) should develop national guidelines for its 

control. 

With joint efforts of neonatologist and ophthalmologist we can handle this 

problem. 

629


In conclusion study suggests that there is lack of awareness and close 

coordination between pediatrician and ophthalmologist for screening and 

service delivery for ROP. So there is intense need for creating awareness to 

overcome these barriers to avoid childhood blindness. 

REFERENCES 

1. Jalali S, Hussain A, Matalia J,. Modification of screening criteria for India and other 

middle-income group countries. Am J Ophthalmol. 2006;141:966-68. 

2. Gilbert C. Retinopathy of prematurity: A global perspective of the epidemics, 

population of babies at risk and implications for control. Early Hum Dev 2008; 

84:77-82. 

3. M.S. Bajaj AIIMS, National programme of control of blindness,paediatric 

ophthalmology pg;17. 

4). SR Sathiamohanraj et al - Awareness of retinopathy of prematurity among 

pediatricians in a tier two city of South India. Oman journal of ophthalmology. 2011; 

Volume 4, Issue 2. 

5. Padmaja Rani, Subhadra Jalali-Knowledge Attitude Practice of Retinopathy of 

Prematurity amongst Pediatricians attending a Neonatal Ventilation Workshop in 

South India 10.5005/jp-journals-10020-1003. 

6. Kemper AR, Wallace DK. Neonatologists’ practices and experiences in arranging 

retinopathy of prematurity screening services. Pediatrics 2007;120:527-31. 

7. Chen Y, Li X. Characteristics of severe retinopathy of prematurity patients in 

China: A repeat of the first epidemic? Br J Ophthalmol. 2006;90:268-71. 

8. Trinavarat A, Atchaneeyasakul L,. Applicability of American and British criteria 

for screening of the retinopathy of prematurity in Thailand. Jpn J Ophthalmol 

2004;48:50-3. 

9. Phan MH, Nguyen PN, Incidence and severity of retinopathy of prematurity in 

Vietnam, a developing middle-income country. J Pediatr Ophthalmol Strabismus 

2003;40:208-12. 

10. Gilbert C, Fielder A, International NO-ROP Group. Characteristics of infants with 

severe retinopathy of prematurity in countries with low, moderate, and high levels 

of development: Implications for screening programs. Pediatrics 2005;115:518-25. 

A Survey to Assess the Compliance of Low 

Vision Aids in Visually Challenged Patients 

Dr. Sara Jacob, Dr. Giridhar A, Dr. Mahesh G., Dr. Ms. Sreeshma T.S. 

In 1993, the World Health Organisation redefined LOW VISION as: A person 

with low vision is one who has impairment of visual functioning even after 

treatment and or standard refractive correction and has a visual acuity of


but who uses or is potentially able to use vision for the planning and execution 

of a task. 1 WHO released the new global estimates on visual impairment in 

2010. WHO estimates that the number of people with visual impairment is 285 

million (65% of whom are aged over 50 years). Of these, 246 million have low 

vision (63% over 50 years). 2 

Aim of the Study: We conducted this study to ascertain the proportion of 

patients who gain benefit from Low Vision Aids (LVAs). To ascertain how 

frequently they used the prescribed LVAs and for what purpose they used 

the LVAs. Did they gain any benefit in the jobs they were employed in? To find 

out the reason why some prescribed LVAs were left unused. To compare the 

types of optical LVAs preferred in the various categories of retinal disorders. 

To compare between the group frequently using their LVAs and the group not 

using their prescribed LVAs. 


A questionnaire and telephone survey was carried out on 83 patients who 

attended our Low Vision Clinic from January 2010 to February 2011 by an 

Ophthalmologist. Their clinical records were retrieved from our Medical 

Records Department and analysed. The questionnaire included questions 

regarding their educational qualification, employment details, usage rate of 

LVA, activities for which LVAs were used, deterioration of vision after the 

prescription of LVA and questions regarding general health were asked. If 

they were not using the prescribed LVA reason for their non-compliance were 

enquired. Data collected were compiled and analysed. Descriptive statistics of 

mean and percentage were used. Statistical analysis was done using Pearson 

Chi-square test. 

RESULTS 

67 patients were contacted. Time since prescribing LVA ranged from 1 month 

to 15 months. The patients included 42(62.7%) males and 25(37.3%) females. 

53(79.1%) patients were in the age group 51-80 years. 44(65.7%) patients were 

using the LVAs prescribed. 19(43.2%) patients used them 3 or more times/ 

day. Patients used their LVAs for newspaper reading, reading religious books, 

magazines, checking minute details, work, study purposes etc. 11(25%) patients 

used them for Work/Study purpose. Majority 33 patients (75%) used them for 

newspaper reading. Average reading ability with prescribed LVAs improved 

from N 12 

to N 6 

. Frequency of LVA usage >10 times/day 7%, 6-10 times/day 16%, 

3-5 times/day 21%, twice daily 16%, once daily 28%, 1-2 times/week 12%. Of the 

23 patients not using their LVAs, 10 felt that the prescribed LVA was not clear 

enough for them to see clearly, 3 felt that it was very strainful to go close, 4 

had severe deterioration of vision, 1 was bedridden, 1 had fear of eyestrain for 

using high powered glass, 2 had difficulty as hands were not free. 14 patients 

631


experienced some degree of deterioration of vision of which 4 patients stopped 

using their LVAs due to severe decrease in visual function. In the study 33(49%) 

patients had Diabetic Retinopathy, 13(19%) patients had Age Related Macular 

Degeneration, 10 (15%) patients had Optic Atrophy, 3(5%) patients had Retinal 

Vein Occlusions and 8 (12%) patients had macular degenerations other than 

ARMD (c/c CSR, PFT, Macular Dystrophy etc). Types of LVAs preferred were 

Prismatic Spectacles 57%, Hand Magnifiers 13%, Stand Magnifiers 18%, Dome 

Magnifiers 6% and Aspheric Spectacles 4%. Patients with Diabetic Retinopathy 

were prescribed prismatic spectacles 19(57.6%), illuminated hand magnifiers 

6(18.2%), stand magnifiers 5 (12.1%), dome magnifiers 2 and aspheric spectacles 

1. Patients with ARMD were prescribed prismatic spectacles 8 (61.5%), stand 

magnifiers 4 (30.8%) and dome magnifier 1. Patients with Optic Atrophy and 

Glaucoma were prescribed prismatic spectacles 5 (50%), illuminated hand 

magnifiers 2(20%), stand magnifier 1, dome magnifier 1 and aspheric spectacles 

1. Chi Square analysis between the groups yielded a value of 4.317 and p value 

0.6339 with no statistically significant association. 

We compared between the group of patients who frequently use the 

prescribed LVA 3 or more times daily and the group of patients who did not 

use their prescribed LVAs. The first group had 19 patients and the second 

group had 23 patients. The educational qualifications appeared to be the same 

in two groups. Chi Square 

value of 0.01375 and p value 

of 0.7108 was obtained with 

no statistically significant 

association. Comparing the 

group frequently using their 

LVA with the group not 

using their prescribed LVA it 

was noted that patients with 

moderate degree of visual 

deterioration (6/36 and worse, 

N 12 

-N 10 

) used their LVAs 

frequently compared to those 

with mild degree of visual 

Comparing the BCVA for Near Between The Group deterioration (Chi-Square 

Frequently Using Their Lvas and The Group Not value of 5.575 and p value of 

Using Their LVAS: 

0.0616 with no statistically 

significant association). In the 

group frequently using LVA 8/19 patients were in 51-60 years category and 

4/19 patients were in 61-70 years category. In the group not using LVA 8/23 

patients were in 71-80 years category and 6/23 patients were in 51-60 years 

category. Therefore increasing age may contribute to non-compliance. 

632


DISCUSSION 

In our study 65.7% of the patients studied were using the prescribed LVA. Mean 

age of the patients were 60.5 years. 43.2% used them 3 or more times per day. 

22.7% used them 6 or more times daily. 25% used them for work/study purpose. 

75% used them for newspaper reading. The prompt implementation of low 

vision aids will help low vision patients to maintain and regain their reading 

ability, which can lead to an increase in independence, communication, mental 

agility and quality of life. In our study 14 patients experienced deterioration 

of vision of which 4 patients stopped using their LVA due to severe decrease 

in visual function. In a study by Roshrschneider et al. 57% used their optical 

LVAs more than 5 times daily mostly for reading and writing (74% and 78%, 

respectively). 3 

In our study the mean magnification required was 3.3X, the range of 

magnification 1.25X to 12X. In a study by Nguyen et al, the mean magnification 

required was 4X. 

In a study by Shuttleworth mean magnification required was 3X, range of 

magnification 1.5X to 20X. 4 In our study average reading ability with prescribed 

LVAs improved from N 12 

to N 6 . In a study by H. Court the average reading 

ability improved from N 12 

to N 5(6) 

. Comparing the group frequently using their 

LVA with the group not using their prescribed LVA it was noted that patients 

with moderate severity of visual deterioration(6/60-6/36, N 12 

-N 10 

) used their 

LVAs frequently compared to those with mild degree of visual deterioration. 

In our study majority of LVAs supplied were prismatic spectacles (+5DS to 

+10DS) -56.7%. Spectacles are the best form of aid for prolonged reading. They 

have the advantage of a larger field and leave both hands free to hold the 

reading material. They are a cheaper and simpler alternative to the costlier 

and complex electronic devices. In a study by Shuttleworth where only simple 

optical aids were used 64% supplied were magnifiers. 4 

In an AMD study by Nhung Xuan et al. visual rehabilitation was achieved 

with optical visual aids in 58% of patients, whereas 42% of patients needed 

electronically closed-circuit TV systems. 5 In a study by N.X. Nguyen et al. 

visual rehabilitation was frequently sufficient with simple optical low-vision 

aids such as high-plus reading additions and magnifiers in 76%. Closed-circuit 

television systems were necessary in 26% 7 Limitations of the study include 

small sample size and inability to assess the reading speed as this study was 

a telephonic survey. 

In conclusion results of this survey show that 65.7% of the visually challenged 

patients are able to improve their quality of life by improving their reading 

ability with the appropriate LVA. It was noticed that prismatic spectacles 

were the most preferred LVAs (56.7%) in this particular series. Patients with 

633


moderate severity of visual loss used their LVAs frequently when compared 

to those with mild visual loss. Simple Optical Aids are a cheaper and simpler 

alternative to the costlier and complex electronic devices 

REFERENCES 

1. World Health Organization. International statistical classification of diseases, 

injuries and causes of death, tenth revision. Geneva, 1993. 

2. WHO 2010:WHOPBD@who.int. 

3. Satisfaction with low vision aids, Rohrschneider K, Kiel R, Pavlovska V, Blankenagel 

A. Klin Monbl Augenheilkd. 2002;219:507-11. 

4. How effective is an integrated approach to low vision rehabilitation? 2 year 

follow up from South Devon. Shuttleworth et al. British Journal of Ophthalmology 

1995;79:719-23. 

5. Improvement of reading speed after providing of low vision aids in patients 

with age-related macular degeneration Nhung Xuan Nguyen, Malte Weismann, 

Susanne Trauzettel-Klosinski. Acta Ophthalmologica. 2009;87:849-53. 

6. How effective is the new community- based Welsh low vision service? H. Court, B. 

Ryan, C. Brunce. British Journal of Ophthalmology 2011;95:178-84. 

7. Spectrum of Ophthalmologic and social rehabilitation at the Tubinger Low Vision 

Clinic: a retrospective analysis for 1999- 2005 Nguyen N.X; Weisman M, Trauzettel- 

Klosinske S. Ophthalmologe 2008;105:563-9. 

Childhood Visual Impairment in Northern India: 

Causes and Its Co-Relation 

Dr. Sunita Mohan 

Estimated that globally almost one in 1000 children are blind. India 

shoulders the world’s largest burden of blindness. Of a total population 

exceeding one billion, as many as 15 million people are blind, and an additional 

52 million are visually impaired. Among these 320,000 children are under 

the age of 16, constituting one fifth of the world’s blind children. Though no 

population based nationwide survey has been undertaken on the prevalence 

of childhood blindness in India, a figure of 0.8/1000 children has been used, 

using the co-relation between under five mortality rates and prevalence. 

Visual impairment has significant implications for the affected child and 

family in terms of education, future employment, personal and social welfare 

throughout life. 

To estimate prevalence of visual impairment in children less than 16 years in 

rural population of Agra. To evaluate these children for probable causes of 

visual impairment. To co-relate these causes with their biosocial profile. 

634



Population based cross-sectional survey, conducted in 3 randomly selected 

villages of Agra district, the population of which is 3.62 million (Census 2001) 

with a rural population of 2.05 million and urban of 1.57 million. The study 

was carried out during August 2006 and March 2008. The Study Population 

comprised of 1096 children less than 16 years of age. Visiting children 

(resident 4 years. Detailed ophthalmic workup was offered to those children 

whose BCVA were not 6/6. 

Data Management and Analysis: Enumeration and clinical data were recorded 

using schedule data forms. Children were divided into three age groups, 10 yrs for comparison of prevalence. Disease prevalence was 

compared between these age groups and both sexes. 

RESULTS 

Demographic profile of study population 

Parameters 

Interpretation 

Age wise data of Examined Children 

Age (in yrs) Boys Girls Number % 

< 5 25 19 44 4 

5 – 10 302 264 566 51.6 

> 10 264 222 486 44.4 

Total 591 505 1096 100 

Literacy Status of Children 

Status Boys Girls Number % 

Illiterate 243 248 491 44.8 

Literate 348 257 605 55.2 

Total 591 505 1096 100 

Majority of population belonged 

to age group 5-10 yrs. (51.6%) 

Average literacy rate: 54.9%. 

The percentage of females 

having 6 or more yrs of schooling 

is 7.2% which is almost half of 

males (13.4%). 

635


Almost 1/3 male children were involved in education whereas 1/3 of females 

were engaged in household work. A total of 79.6% females were engaged in 

some or other kind of occupation besides studying, whereas for males the 

figure for same is 55.0%. Children not engaged in any kind of work were 11.4% 

of 1096 children. Average Adult literacy rate was 38.45%. Adult female literacy 

rate (30.0%) was lower than the adult male literacy rate (47.8%). Most of the 

children with low vision belonged to age group 5-10 years. Prevalence of 

blindness noted was 1.46%(16). 

Anatomical site of major causative pathology 

636 

Site Frequency Prevalence/1000 

Whole Globe 3 2.7 

Microphthalmos 2 1.8 

Coloboma 1 0.9 

Cornea 5 4.5 

Opacity (VAD) 2 1.8 

Opacity(Ophthalmia neonatorum) 1 0.9 

Traumatic rupture 2 1.8 

Optic Nerve 3 2.7 

Secondary Optic atrophy 3 2.7 

Cataract 3 2.7 

Congenital 1 0.9 

Traumatic 2 1.8 

Retina 1 0.9 

Albinism 1 

Others 1 0.9 

Glaucoma 1 

Total 16 14.6 

The relatively high proportion of corneal scarring found in this study is mainly 

a reflection of poor socioeconomic status, which is associated with inadequate 

immunisation coverage (23.3% children were unimmunised against measles), 

poor nutrition and health services for children. 8.3% children showed bitot’s 

spot, of which 91.2% children were PI/UI. Statistically significant difference in 

prevalence of Xerophthalmia was observed between male and female children 

(X 2 =25.564, P value = 0.0000387). Difference of prevalence of Xerophthalmia 

in partially immunised and unimmunized categories was statistically 

significant. (X 2 =461.854, P value = 1.07x10- 94 ). 

Aetiological Categorie 

Childhood factors along with infectious factors accounted for the majority of 

cases in this study (62.5%). In a significant proportion of these cases (37.5%),


the underlying aetiology could not be determined. In most children it was not 

possible to determine the time of onset owing to lack of reliable history and 

medical records, or the pathological processes could not be elucidated. 

Avoidable Causes 

Preventable conditions No. of children Percentage 

VAD 2 4 

Ophthalmia neonatorum 1 2 

Trauma 4 8 

Meningitis 3 6 

Refractive Error 34 68 

Subtotal 44 88 

Treatable conditions 

cataract 1 2 

glaucoma 1 2 

Subtotal 2 4 

Total avoidable 46 92 

In this study, 75% of blind children had avoidable causes of visual loss. Trauma 

contributed to the majority (25%) of the preventable causes. Almost all the 

trauma cases were seen in males. Childhood cataract (2 due to tauma, 1 due to 

congenital causes) was one of the main treatable conditions in our study. 

Prevalence of Refractive Error 

Out of total 1096 children examined, 126 (14.5%) were found to have refractive 

errors. Out of 126 children with refractive error, 54 (4.9%) were boys and 72 

(6.6%) were girls. After correction only 34 children (3.1%) had less than 6/18 

vision in their better eye. Corrected vision less than 6/60 - 3/60 in the better eye 

was seen in 8 (0.7%) children. Statistically significant difference in prevalence 

of refractive error was observed between different age group. (X 2 = 26.774, P 

value = 0.0000221). Although there was difference in prevalence of refractive 

error between boys and girls, it was not statistically significant. ( X 2 = 0.539, P 

value = 0.764). Majority of children belonged to the middle class, however this 

difference was statistically not significant. (X 2 = 3.087, P value = 0.929). Of 126 

(11.5%) children with refractive error 88 (8.0%) children had literate parents, 

52 literate mothers and 88 literate fathers, however no significant difference 

was seen between these groups .(Mother X 2 = 0.590, P value = 0.745 Father X 2 = 

0.865, P value = 0.649). 

Profile of visual status in surveyed children: Prevalence of low vision in children 

was high , 4.6% of which 2.2% contributed to economic blindness which was 

more prevalent in girls. Social blindness was equal in both girls and boys. 

Economic blindness and social blindness was more in the younger age group, 

637


Aetiological Categorie 

Etiology No. Socio Economic Status Immunisation Status 

Vit.A Measles 

I II III IV V FI PI UI I UI 

Childhood: 

Vitamin A deficiency 2 - - - 1 1 -¬ - 4 - 4 

Trauma 4 1 1 2 - - 3 1 - 4 - 

Abnormalities Since birth: 

Cataract 1 - - - 1 - 1 - - 1 - 

Glaucoma 1 - - - 1 - 1 - - 1 - 

Albinism 1 - 1 - - - 1 - - 1 - 

Microphthalmos 2 - 1 1 - 2 - - 2 - 

Coloboma 1 - - 1 - - 1 - - 1 - 

Infectious : 

Secondary Optic atrophy 3 - - 2 1 - 1 - 2 1 2 

Ophthalmia neonatarum 1 - - 1 - - - - 1 - 1 

Total 16 1 3 7 4 1 10 1 7 11 7 


status, Poor literacy rate, Inadequate Immunisation were reinforced. Following 

recommendation are proposed based on observations made in our study. 

Strategies for Serving the Underserved : Short term year : 1 to 3 years Plan: 

Includea Campaign approach, Stimulating Political awareness, political 

will and commitment, including local communities, Harnessing existing 

knowledge and skills, Mobilizing the necessary human capital, Delivering 

quality services based on need, Supporting local demonstration projects, 

Provision of financial and human resources. 

Long term interventions: 1 to 5 years plan include Identifying and demarcating 

areas that are underserved, Revise policies and strategies to strengthen 

the health delivery system for the underprivileged as a priority Institute 

or strengthen PHC and infrastructure. Priority areas to control childhood 

blindness: Development of Pediatric Ophthalmology Units at tertiary level eye 

care centres , Strengthening of refraction services at Primary and Secondary 

level of Eye Care Screening and detection of avoidable/preventable causes 

of blindness (ocular trauma and retinopathy of pre-maturity); Provision of 

low vision devices at low/no cost. The eyes do not see what the mind does 

not know. The Heart makes a difference. When the Heart is involved there is 

concern, compassion and empathy .Then the mind wants to know: Where is 

the problem? What is the problem? How to overcome the problem? It is only 

then that we can Reach the Un-reached. 

Cataract Care Services for Children: Barriers 

Encountered in Rural and Backward Regions 

Dr. Jayashree Baruah, Dr. Deva Prasad Kar, Dr. Sanjib Buragohain, 

Dr. Mrinal Modhur Borgohain 

Globally there are at least 190,000 children blind due to cataract. Childhood 

cataract is the most common treatable cause of childhood blindness, 

being responsible for 10-30% of all childhood blindness. Surgical intervention 

is the treatment of choice for children who are born with or who develop 

cataract later. But, such children blinded by cataracts should be operated as 

soon as possible. Delay in presentation results in less than optimal visual 

outcome after surgery. Although significant progress has been made in the 

field of surgical management of congenital cataract, uptake of cataract surgery 

in children is low in most resource poor countries. 

The purpose of this study was to discuss the barriers associated with providing 

proper cataract care services for children in rural and backward regions. 

639



This is a retrospective study conducted at a community eye care centre 

in Uttarakhand from Jan’09 to Nov’10. The study population comprised 

of all children under the age of 16, presenting with congenital and/or 

developmental cataract. Ethical approval for the study was obtained from the 

ethics committee of the hospital. Informed consent was taken from caregivers 

before the interview. Parents or guardians of all children presenting to our 

hospital with congenital or developmental cataract were interviewed with 

special questioniers, regarding the actions taken and timing of these, before 

coming to hospital. The questions were designed to enable us to know the 

barriers to early detection, early referral and uptake of surgical procedures in 

children. Demographic information was also collected. The predictors of late 

presentation were assessed. 

RESULTS 

At our institute, 84 children were operated between Jan’09 to Nov’10, of which 

28 were congenital and 56 developmental cataract. 48 were male and 36 female. 

Table 1: Table Showing Delay Period Between Recognition of The 

Condition To Presentation To Hospital 

Sl. No. Period (in mon) No. of Cases 

1 0-3 1 

2 3-6 12 

3 6-9 31 

4 9-12 12 

5 12-15 1 

6 15-18 2 

7 18-21 0 

8 21-24 17 

9 24-27 1 

10 27-30 4 

11 30-33 2 

12 33-36 1 

Among children with congenital cataract, having another sibling increased 

the likelihood of early presentation, possibly because their expectations of 

achievable sight at a young age are based on previous experience of their 

older children. A long delay in presentation was associated with having 

developmental cataract. 

640


Table 2: Table Showing The Most Common Barriers Noted in Our Study 

Sl.No. Cause No. of Cases 

1 Unawareness of parents that the child is suffering 63 

from a treatable condition 

2 Lack of knowledge amongst primary level health care 36 

provider (traditional and modern) to detect childhood cataract. 

3 No access to eye care services 15 

4 Family decision not to seek advice 25 

5 Lack of referral or inappropriate advice from traditional 29 

or modern health practitioners 

Thus, overcoming these barriers is important for developing a framework for 

care. 

DISCUSSION 

Blindness caused by childhood cataract in developing countries is primarily 

a result of inadequate or timely use of surgical services. The shorter the 

duration between onset of visually impairing cataract and surgery, the greater 

the likelihood that surgical intervention will lead to a good visual outcome. 

Children with congenital cataract are more likely to have mature cataracts 

leading to severe visual deprivation compared to children with developmental 

cataract in whom the cataract may develop more gradually. Regardless of the 

type of cataract, early presentation is important for visual outcome. 

The excessive delay in presentation in our study population suggests that 

there are barriers to presentation to surgery, including awareness of the 

problem (and surgical interventions), access to surgical services, or acceptance 

of surgical services. The major delay occurred between recognition and 

presentation (the time the caregivers recognised the problem and sought care 

from a health worker) rather than between the presentation to treatment delay. 

This suggests that the primary barriers exist at the community level rather 

than the provider level; however, presentation to treatment delay is still too 

long. 

Parental understanding of the natural growth and development of infants 

is a function of community norms as well as experience with raising older 

children. This understanding becomes much more refined after the experience 

of observing a child progress through stages of infant development. Thus, 

the finding that children with congenital cataract who had a sibling (an older 

sibling) were brought to the hospital sooner than congenital cataract cases 

without a sibling seems logical. 

In conclusion this study proposes that the starting point for comprehensive 

eye care for children should always be an understanding of the barriers 

641


to providing cataract care services to children especially in rural and 

backward areas. It also emphasizes the need for establishing community 

action for children with cataract while at the same time ensuring that the 

infrastructure is in place to meet the need for services. Delay in presentation 

remains a significant problem for children needing surgery for congenital 

or developmental cataract. Educational efforts should aim to reach the most 

‘unreachable’. 

REFERENCES 

1. Foster A, Gilbert C, Rahi J. Epidemiology of cataract in childhood: a global 

perspective. J Cataract Refract Surg. 1997;23:601–4. 

2. Rahi JS, Dezateux C. National cross sectional study of detection of congenital 

and infantile cataract in the United Kingdom: role of childhood screening and 

surveillance. The British Congenital Cataract Interest Group. BMJ 1999;318:362–5. 

3. Gilbert C, Rahi JS, Quinn GE. Visual impairment and blindness in children. In: 

Johnson GJ, Minassian DC, Weale RA, et al, eds. Epidemiology of eye diseases. 

London: Arnold Publishers, 2003. 

4. Kello AB, Gilbert C. Causes of severe visual impairment and blindness in children 

in schools for the blind in Ethiopia. Br J Ophthalmol 2003;87:526–30. 

5. Waddel KM. Childhood blindness and low vision in Uganda. Eye 1998;12:184–92. 

6. Van Dijk K, Courtright P. Barriers to surgical intervention among blind and low 

vision children in Malawi. Visual Impairment Res 2000;2:75–9. 

7. Yorston D, Wood M, Foster A. Results of cataract surgery in young children in east 

Africa. Br J. Ophthalmol 2001;85:267–71. 

8. Lewallen S, Roberts H, Hall AB, et al. Increasing cataract surgery to meet Vision 

2020 targets: experience from two rural programmes in east Africa. Br J Ophthalmol 

2005;89:1237–40. 

Visual Impact of Community Cataract Services by 

a Tertiary Eye Care Centre in Rural Central India 

Dr. Ritesh Patidar, Dr. Rahul Shah, Mr. Subramaniam Swami, Dr. Elesh Jain 

Cataract is the leading cause of blindness worldwide, and is particularly 

common in poor and developing countries. Of the total estimated 38 

million blind people in the world, 9–12 million are in India. 1,2 Report estimates 

that 50%–80% of these people are blind because of cataract. 1,2 

Uttar Pradesh (U.P.) and Madhya Pradesh(M.P.) are those states of India which 

are poor, underdeveloped, lacking resources and having large number of rural 

population. 3 Our study based on community based cataract services in rural 

areas of 4 districts of M.P.- Satna, Panna, Rewa and Chhatarpur and 7 districts 

642


of U.P.- Allahabad, Banda, Fatehpur, Hamirpur, Kaushambhi, Chitrakoot and 

Mahoba. These districts cover around 1.86% of total Indian population (census 

2011). 4 

Productivity per individual surgeon/unit should be increased through a high 

volume, high quality cataract surgery approach to solve the problem of India’s 

curable blindness. 5 This need increase in number of cataract surgeries, while 

maintaining high quality surgery. Some recent studies of high volume cataract 

surgery in India and Nepal report good results. 6,7,8,9,10,11,12 Cataract Surgery Rate 

(CSR) is no. of cataract surgeries done per million populations in a year. Target 

CSR in India is presently 4000/million/year. 13 

To study Visual Impact of Community Cataract Services conducted by 

Sadguru Netra Chikitsalaya, Chitrakoot for reducing blindness due to cataract 

in M.P. and U.P. 


Our study design was retrospective Analysis. Total 54,322 Cataract patients 

through outreach camps, vision centers and teleophthalmology from 4 

districts of M.P. and 7 districts of U.P. mentioned earlier in study operated 

from April 2008 to March 2011 at Sadguru Netra Chikitsalaya, Chitrakoot 

included in the study. Patients operated for cataract at our hospital which 

are not under CCS were not included in study. Surgical procedures were 

Extra Capsular Cataract Extraction (ECCE), Small Incision Cataract Surgery 

(SICS) and Phacoemulsification with PCIOL implantation. Cataract Surgery 

Rate (CSR) calculated for yr. 2008-09, 2009-10 and 2010-11. Preoperative and 

postoperative 1 month follow-up visual acuity noted and categorized. 

RESULTS 

Cataract surgeries performed by Community Cataract Services(CCS) of our 

hospital: 

2008-09:- 10,604 

2009-10:- 20,837 

2010-11:- 22,881 

Year wise data of patients through outreach, vision centres and teleophthalmology: 

Year Outreach Vision Tele- Total Growth 

camps Centres ophthalmology from Yr. 08-09 

2008-09 10604 0 0 10604 

2009-10 12840 (61.62%) 7997 (38.38%) 0 20837 196.5% 

2010-11 12515 (54.70%) 9014 (39.39%) 1352 (5.91%) 22881 215.78% 

643


Comparison of total cataract surgeries and cataract surgeries under CCS at 

our hospital: 

Year Total cataract surgeries at Cataract surgeries under CCS % 

our hospital 

2008-09 66,730 10,604 15.89% 

2009-10 77,684 20,837 26.82% 

2010-11 82,602 22,881 27.70% 

Population coverage of Community cataract services of our hospital was 

2,15,09,389 in year 2008-09; 2,19,16,287 in year 2009-10 and 2,23,30,882 in year 

2010-11. 

Cataract Surgery Rate of community cataract services of our hospital: 

2008-09: 493/million/yr. (12.32% of target) 

2009-10: 950.75/million/yr. (23.77% of target) 

2010-11: 1024.63/million/yr. (25.62% of target) 

Visual acuity analysis (BCVA) results: 

Year Pre-op. BCVA 1 Month Follow-up BCVA 

6/6-6/18 6/24-6/60


The post operative visual outcome was comparable with other studies. High 

volume cataract surgeries in our study were not compromising quality of 

surgery (92.44% patients having post operative BCVA between 6/6-6/18). 

In conclusion community cataract services of our hospital were effective for 

reducing burden of blindness due to cataract in the catchment areas. Quantity 

of surgeries did not compromise quality of visual impact. 

REFERENCES 

1. Jose R . National programme for control of blindness. Indian J Commun Health 

1997;3:5–9. 

2. Dandona L , Dandona R, Naduvilath T, et al. Is the current eye-care policy focus 

almost exclusively on cataract adequate to deal with blindness in India? Lancet 

1998;351:1312–6. 

3. http://www.planningcommission.gov.in/aboutus/speech/spemsa/msa007.pdf 

4. Census of india 2011- http://www.censusindia.net; http://censusindia.gov.in 

5. Natchiar G , Robin AL, Ravilla D, et al. Attacking the backlog of India’s curable 

blind. Arch Ophthalmol 1994;112:987–93. 

6. Natchiar G , DabralKar T. Manual small incision suture less cataract surgery—an 

alternative technique to instrumental phacoemulsification. Operative Techniques 

Cataract Refract Surg. 2000;3:161–70. 

7. Balent LC, Narendran K, Patel S, et al. High volume sutureless intraocular lens 

surgery in a rural eye camp in India. Ophthalmic Surg Lasers 2001;32:446–55. 

8. Prajna NV, Chandrakanth Ks, Kim R. et al The Madurai intraocular lens study II: 

Clinical outcomes. Am J Ophthalmol 1998;125:14–25. 

9. Civerchia L , Apoorvananda SW, Natchiar G, et al. Intraocular lens implantation in 

rural India. Ophthalmic Surg Lasers 1993;24:648–53. 

10. Civerchia L , Ravindran RD, Apoorvananda SW, et al. High volume intraocular 

lens surgery in a rural eye camp in India. Ophthalmic Surg Lasers 1996;27:200–8. 

11. Ruit S , Tabin GC, Nissman SA, et al. Low cost high volume extracapsular cataract 

extraction with posterior chamber intraocular lens implantation in Nepal. 

Ophthalmology 1999;106:1887–92. 

12. Hennig A , Kumar J, Yorston D, et al. Sutureless cataract surgery with nucleus 

extraction: outcome of a prospective study in Nepal. Br J Ophthalmol 2003;87:266– 

70. 

13. Textbook of Preventive and Social Medicine , Park’s ,20th edition 

14. Moses C. Chirambo et al; Community Eye Health 2002;Vol 15, No. 44 

15. Lalit Dhandhona et al; Community Eye Health 2000;Vol 13 No. 35. 

16. Causes of poor outcome after cataract surgery in Satkhira district, Bangladesh; R 

Lindfield et al. Eye 2008;22:1054–6; doi:10.1038/sj.eye.6702836; published online 13 

April 2007. 

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Paediatric Low Vision: Magnitude, Interventions, 

Determinants and Compliance 

Dr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, 

Dr. Sudhir Taras 

To assess the low vision problem and its management along with impact 

assessment in paediatric population 

Objectives : A study in paediatric population (children from blind schools 

and paediatric patients visiting the low vision department of a tertiary eye 

care centre) between October 1st 2007 and October 1st 2008, so as to - 

1. Find out the magnitude of low vision in children aged 0-16 years in two 

sample populations, viz schools for the blind and a tertiary eye care 

hospital. 

2. Identify the determinants (causes) of low vision in children. 

3. Manage / treat the children with low vision by providing low vision 

devices (optical and non optical) and giving suggestions for environmental 

modifications. 

4. Assess the compliance and impact on the quality of life at the end of 3 

months and 9 months. 


• cross-sectional study was done ; 

• a comprehensive data was collected from children aged 0-16 years, 

attending schools for blind in and around Pune between November 1st 

2007 and September 1st 2008. 

• Entire examination done by a team of ophthalmologists, low vision 

specialist, optometrist and retina specialist. 

• Data collected comprises clinical and demographic details and educational 

status. 

• Case record includes a special modified version of WHO/PBL eye 

examination record for children with blindness; including entire low 

vision assessment ,prescription of low vision devices. 

• The record has a detailed history with age at onset of visual loss, 

consanguinity and cause of visual impairment . 

• Visual functions were assessed using Lea symbols chart for distance 

and near acuity, Low contrast Flip chart with Lea symbols for contrast 

sensitivity 

646


• Complete refraction followed by Evaluation for low vision aids was done. 

• Appropriate spectacle and low vision aid (optical and/or non optical) - 

provided based on the needs with specific training to use them. 

• Compliance was checked by observation in the follow up (whether child 

was wearing/using the aid or not) and by verbal questions regarding the 

reason for not using the aid. 

• Assessment of outdoor and indoor activities was done by means of leading 

questions related to mobility ,recognition of faces and objects ,own daily 

routine work, playing , art work (cane work)was also done 

RESULTS 

• In the schools for blind 19.1% children and in the tertiary eye care 1.7% 

were found to have low vision 

• Majority of children from the schools for blind, i.e. 51.7%, had whole globe 

anomalies like microphthalmos as the determinant of low vision followed 

by retinal causes like heredomacular degeneration etc. (28.3%) and others. 

On the other hand, the majority of children from the tertiary eye care 

centre had retinal lesions as the determinant of low vision followed by 

whole globe anomalies 

• In the schools for blind, 16.7% children improved to the 6/18-6/9 range 

of distance vision. All the children with vision (less than)


happy with the aid. In tertiary eye care centre: only 1.9% found it difficult 

to use the aid and another 1.9% broke the aid 

• 96.7% children from schools for blind and 92.5% from tertiary eye care 

centre were dependent in their mobility but with the use of aids provided 

61.7% from the schools for blind and 52.8% from the tertiary eye care centre 

became independent. 

• 58.3% children from schools for blind and 35.8% from tertiary eye care 

centre could comfortably play outdoors with the aids provided. 

• 5% children from schools for blind and 7.5 % from the tertiary eye care 

centre could cross the roads independently with the aids provided 

• With regular use of aids: 35% children from schools for blind and 45.3% 

from the tertiary eye care centre learnt to read. 63.3% children from schools 

for blind and 50.9% from the tertiary eye care centre started to recognize 

faces and objects at 3m. 61.7% children from schools for blind and 41.5% 

from the tertiary eye care centre could wash and maintain their clothes 

better with the aids 

In conclusion Low vision/ “partial sight” can be managed well with low vision 

services thereby improving the quality of life of children with low vision. 

Thus,its important to screen out patients of low vision from blind schools to 

provide them with appropriate aids. 

More so in children as early management and provision of aids will help them 

cope with their daily needs, social and educational needs as well. 

Retinopathy of Prematurity is A Major Cause of 

Childhood Blindness in Pune Region 

Dr. Kuldeep Dole, Dr. Madan Deshpande, Dr. Sucheta Kshirsagar, 

Dr. Tanmayi Dhamankar 

Retinopathy of prematurity (ROP) is a vasoproliferative retinopathy which 

occurs principally, but not exclusively, in premature infants of very low 

birth weight who have been exposed to high ambient oxygen concentrations. 1 

It occurs in 2 overlapping phases: 

1) An acute phase in which normal vasculogenesis is interrupted and a 

response to injury is observable in the retina. 

2) A chronic or late proliferative phase in which membranes grow into 

the vitreous causing tractional retinal detachment,ectopia or macular 

scarring leading to severe visual loss. 

648


The proportion of childhood blindness due to retinopathy of prematurity in 

different parts of the world : Europe- 17%, L.America-38.6%, E.Europe: 25.9%, 

Asia: 16.9%, Africa: 10.6%. 

[SOURCE: Gilbert C.,Retinopathy of Prematurity Epidemiology, Journal of 

Community Eye Health 10(22):22-4] 

In developing countries with a human development index (HDI) of 31-100, 

ROP is emerging as a major cause of blindness. The reasons were higher 

premature birth rates and compromised neonatal screening as a result of a lack 

of resources, lack of awareness, skilled personnel and financial constraints. In 

poorly developed countries (United Nation Development Program [UNDP] 

ranking



A duration based cross sectional study was conducted between 1st October 

2010 and 31st March 2011 in children from three schools for the blind in Pune 

as well as children attending paediatric clinic at H V Desai Eye Hospitl, Pune, 

after obtaining clearance from institutional ethics committee and written 

consent from the respective head of institution of the schools for the blind for 

the examination of inmates. 

Complete Ophthalmological examination as per the Who/Pbl Eye Examination 

Record for Children with Blindness and Low Vision 6 was done using preverbal 

visual acuity charts (for children of 0-6 years) and LogMAR visual acuity charts 

(for children of 7-16 years), slit lamp, direct and indirect ophthalmoscopes and 

90D lens wherever possible. Indian definition of blindness was used- best 

corrected visual acuity


Among those blind due to retinal causes in the schools for the blind,,14 (25%) 

children had ROP ,while the corresponding figures for OPD children were 13 

(44.8%). 

Demographic Description of Children with Rop Blindness 

School Data: (Total 14) 

Age and Gender distribution: 0-5 yrs – 1, 6-10 yrs- 8, 11-16 yrs- 5 

Males: 5, females: 9 

OPD Data: (Total 13) 

Age and gender distribution: 0-5 yrs- 12, 6-10 yrs- 1 

Males: 9, females: 4 

Among the 13 OPD children, 5 underwent vitrectomy with anatomical success; 

they are being followed up for visual recovery. 

DISCUSSION 

As compared to previous blind school studies from Maharashtra, the 

percentage of retinal blindness in general has increased. In the schools for the 

blind, 22.7% were blind due to retinal causes and 6% due to ROP alone. The 

corresponding figures for OPD children were 44% and 22% respectively. The 

data from schools reflects trends of about 10 years ago. The OPD data reflects 

current trends as most of the examined children were under 5 years of age. 

Hence we can say that blindness due to ROP is truly on the rise. 

All children with ROP from the schools as well as the OPD were from urban 

areas. This shows that premature babies are more likely to survive in urban 

areas as a result of improved neonatal intensive care and hence more likely to 

develop ROP. Also, families from urban areas are more likely to enroll their 

children in blind schools and seek consultation at a tertiary eye care centre. 

None of the affected children had any additional disabilities. 

In conslusion ROP is emerging as a major cause of childhood blindness as a 

result of increased survival of premature and low birth weight babies owing 

to the improved neonatal care facilities, especially in urban areas. The facilities 

for screening for ROP are still lacking in these centres. 

Hence,there is an urgent need to establish ROP screening programme and 

train more people in detection and treatment of Retinopathy of prematurity 

.Also a monitoring mechanism should be established for neonatal intensive 

care units to prevent occurrence of ROP. This is especially relevant in urban 

areas where survival of premature babies has increased. 

651


REFERENCES 

1. Terry TL,Extreme prematurity and fibrovascular overgrowth of persistent vascular 

sheath behind each crystalline lens. Am J Ophthalmol 1942;25:203. 

2. Nazimul H.,Khanna R.,Anjli H., Expert Rev Ophthalmol. 2008;3:43-50. 

3. Agarwal R. et al, Changing profile of retinopathy of prematurity, J Trop Paediatr 

2002;48:239-42. 

4. C Gilbert, Retinopaty Of Prematurity: A Global perspective of the epidemics, 

population of babies at risk and implications for control. Early Human Development 

2008;84:77-82. 

5. Gogate et al, Changing pattern of childhood blindness in Maharashtra, India. Br J 

Ophthalmol 2007;91:8-12. 

6. Preventing Blindness in Children, WHO Publication Number WHO/PBL/00.77, 

1999. 

7. Gogate P, Kishore H, Dole K, Shetty J, Gilbert C, et al. The pattern of childhood 

blindness in Karnataka, South India. Ophthal Epidemiol. 2009;16:212–7. 

8. J S Titiyal, N Pal, G V S Murthy, S K Gupta, R Tandon, R B Vajpayee, C E Gilbert. 

Causes and temporal trends of blindness and severe visual impairment in children 

in schools for the blind in North India. Br J Ophthalmol 2003;87:941–5. 

Assessment of Compliance in Children (0-16 Yrs) 

using Low Vision Aids 

Dr. Rahul Deshpande, Dr. Ananta Joseph, Dr. (COL) Madan Deshpande, 

Dr. Sudhir Taras 

To check the compliance in children using low vision aids and thereby its 

impact on their quality of life. 

A study in paediatric population (children from blind schools and paediatric 

patients visiting the low vision department of a tertiary eye care centre) 

between October 1st 2007 and October 1st 2008, so as to Assess the compliance 

and impact on the quality of life at the end of 3 months and 9 months. 


After a complete low vision evaluation appropriate aids were prescribed to 

the children. The use of the prescribed device was demonstrated and children 

were taught to use it before dispensing in order to ensure good compliance. 

Instructions regarding the do’s and don’ts were explained in the local language 

when the trial was over. Instructions about the needed environmental 

modifications were also given, e.g. seating arrangement in the class room. 

652


Next follow up date was given to the patient: first at 3 months and second at 

9 months from the first assessment/visit. Two follow up examinations were 

done at three months and nine months respectively from the first examination. 

Children and accompanying guardian were advised to report for the next 

follow up visit with the aid prescribed. At each follow up visit, the compliance 

and change in the quality of life of these children were assessed. 

Examination at each follow up visit included an ophthalmologic work up 

including torch light examination, assessment of best corrected visual acuity, 

and the children were administered a questionnaire to assess the use and 

satisfaction with the device in the interim period. Direct questions were asked 

regarding the use of the device provided and the reasons, if any, for not using 

it as well. The quality of life was assessed on the basis of the changes noticed 

in mobility, recognition and other outdoor, routine and vocational activities. 

Additional/ new activities, which the children had started performing after 

using the devices provided, were also noted as told by the children. 

RESULTS 

• In schools for blind: Out of initial 60 children with low vision, 44 [73.3%] 

children were present during the second follow up and 21.7% were using 

the aid as advised. In tertiary eye care centre: Out of the 53 children with 

low vision, 36 [67.9%] were present for the second follow up and 66% were 

using the aid as advised. Thus, at the second follow up more number of 

children from tertiary eye care centre were found using the aids 

• Out of 60 children from schools for blind who were given aids, only 8.33% 

broke their aids while 2 [3.3%] found it difficult to use the aid, 6 [10%] left 

the aid somewhere. This suggests that only 8 children probably did not 

appreciate any significant improvement in their activities over a longer 

period (9 months from first examination) with the aids. 

• With the use of aids provided 29 [48.3%] of the initial 60 children with low 

vision from the schools for blind and 31 of the 53 [58.5%] from the tertiary 

eye care centre were independent in their mobility. Out of 60, 30 children 

from schools for blind and 19 of 53 from tertiary eye care centre could 

comfortably play outdoors. 5% children from schools for blind and 7.5 % 

from the tertiary eye care centre could cross the roads independently with 

their aids. 

• At second follow up 23.3% children from the schools for blind could 

read and write. 48.3% had better recognition of faces and objects at 3m 

and could wash; maintain their clothes better. In tertiary eye care centre 

50.9% children were found to be able to read and write. 62.3% had better 

recognition of faces and objects at 3m and could wash; maintain their 

clothes better. 

653


• 46.7% children from the schools from blind and 60.4% from the tertiary eye 

care centre improvement in the craft work. This is statistically significant 

by t-test, p value


4. To review, analyze and study at least 10% operated patients 

5. To verify optimal utilization of the resources. 

Methodology 

Tulsi eye hospital conducts two types of audits to achieve the above aims. 

1. Medical field audit 

2. Patient care audit 

The community ophthalmic outreach programme of Tulsi eye Hospital is 

spread over in six districts and covers 2.5 million population. For medical 

field audit a separate auditor who is a senior ophthalmologist in the city is 

appointed. The list of operated patients is provided to the auditor. The auditor 

does random selection of area and random sampling of the patients. The list 

is given to the concerned social worker of that area and the patients are called 

at the nearby center established by the hospital for routine follow-up and pick 

up of the patients. In each visit approximately 35 to 40 patients are called and 

examined. Auditor makes monthly 2 visits to project catchment area. Thus in 

a year almost 800 -900 patients are examined by the auditor against the target 

of 8000 free surgeries per year (10%). 

The patients who are operated in between 3 mths to 1 year are selected for the 

audit. Audit team comprises of Auditor, Optometrist or Ophthalmic assistant 

and social worker. Auditor is provided with hand held slit lamp and hand held 

autorefractometer. A questionnaire is provided to the auditor. 

After the audit report is prepared it is submitted to the hospital authorities. 

The previous medical record of the patient is checked to find whether it is a 

surgical complication or pre-existing problem or newly arrived ocular problem. 

Problematic patients are again called to the base hospital for treatment. 


Mission for Vision which is the umbrella body under which Tulsi Eye Hospital 

functions has a dedicated Patient Care Team who is responsible for evaluating 

the quality of Patient Care that is provided by the hospitals to all the patients. 

The patient care team ensure the highest level of care to the patient, be it at 

the camp, during transit or at the hospital. The team conducts an ongoing 

evaluation with the parameters constantly being modified and improved with 

an aim to know whether complete ophthalmological care is provided to every 

patient with dignity. 

Team is leaded by General Manager –Patient Care under whom there are four 

Zonal coordinators and under each zonal coordinator there are 5-6 field social 

workers. 

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Following activities are carried out by patient care department: 

a. Door to door survey 

b. Involving in camp activity 

c. Monitoring and documenting the results. 

d. Conducting field level impact study 

e. Case study selection 

f. Referring and follow-up of problematic cases 

RESULTS 

Patient Care Audit (April 2010 March 2011) 

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Patients Surveyed (Nos) 1014 

Eyes Surveyed (Nos) 1334 

One Eye Operated (Nos) 694 

Both Eyes Operated (Nos) 320 

Male | Female 412 I 602 

Percentage (%) 41% I 59% 

Vision Acuity classification 

Survey vision 

(best corrected) Eyes (Nos) Percentage (%) 

Good (6/6-6/18) 763 88% 

Borderline(6/24-6/60) 96 11% 

Poor(


management like YAG laser, secondary IOLs, Refractions 

e) It helped us in improvising the instructions given on the discharge card. 

f) It helped us to modify the diet given to the patients. 

g) Females are more compared to males for free surgeries. 

DISCUSSION 

There are many charity hospitals in India giving comprehensive eye care to 

poor and downtrodden people in affordable cost or even free. These hospitals 

majority of the times run on donations or on some government schemes. 

Patients are admitted in the hospital for minimum three days. As patients 

come from long distance it is usually preferred that they will be discharged 

next day. When patients are admitted in the hospital usually they are under 

obligation and fear. So to get a proper feedback about the hospital services we 

have started with this patient care audit and medical field audit. 

Patients are selected for medical field audit who are operated in between three 

months to one year because the hospital team is in contact with the patient for 

two months in which three consecutive follow-ups of 15 days interval are done 

and in 4th follow-up they get spectacles. Patient care audit team does door to 

door survey to know socioeconomic condition and impact and to collect case 

studies. They attend even the follow-up camps to know about patient comfort 

in the hospital 

The audit is done to measure the quality of care we provide against relevant 

standards. It is helping us to set priorities and make improvements. It has 

created a confidence in the management about proper and optimal utilization 

of its resources 

We cannot compare our findings with any other data or literature because to 

the best of our knowledge this is the first survey or audit done at the field by 

actual interaction with the patients. 

In conclusion: 

1. Medical field audit is an effective and powerful tool which can be used 

to monitor Quality in eye care delivery and to provide evidence for the 

specific resources to increase quality standards or performance 

2. As we remain in contact with the patients for a long period it helped us 

in building the name of the hospital in the society and mouth to mouth 

publicity and improves patient confidence about the service delivery. 

3. It monitors the performance continuously to ensure results and identifies 

trends in attendance for eye surgery 

4. Third party Audit gives unbiased picture. 

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School Eye Health Screening Programme in 

Ahmedabad District – ‘Making The Invisible 

Visible’ 

Dr. Priyanka Gupta, Dr. Pina Rasiklal Soni, Dr. Minal Patel 

The school going years are the formative years for determining one’s 

physical, intellectual and behavioural development. Any problem in 

vision during the formative years can hamper the intellectual development, 

maturity and performance of a person in his future life. Children in the school 

going age represent over 25% of the population in the developing countries. 

Every five seconds one person in the world goes blind…and a child goes blind 

every minute. Childhood blindness is one of the most tragic and wasteful 

global problem. The teachers see their pupils daily so it is possible for them 

to observe the behaviour of their students to facilitate early detection of eye 

problems. 


This is a retrospective study conducted in the schools of Ahmedabad district 

in the year 2009 to evaluate the usefulness of school teachers in detecting 

ocular morbidity amongst school children. The school eye health screening 

programme was initiated by District Collector of Ahmedabad in association 

with district development officer, district education officer, district health 

officer, civil surgeon and programme officer of District Blindness Control 

Society. As a part of the programme, the Principal of school selected teachers 

for vision screening task. The general norm is one teacher per 300 students 

per school. The teachers were then given one day training and kits by the 

ophthalmic assistants. The teachers then screened the students according to 

the set criteria. Students not able to recognize the E chart at 6 metres distance 

with each eye separately in bright light or having other eye problems were 

then included in the list. Ophthalmic assistants screened these students as 

well as the students not covered by the teachers. Children with minor ailments 

were treated on the spot in the school. Children requiring examination by 

specialists were sent to the related referral centers. Spectacles were distributed 

amongst students with refractory errors. 

RESULTS AND DISCUSSION 

Eleven talukas (including Ahmedabad city) of Ahmedabad district have a 

total of 1800 schools out of which 1245 (69.16%) schools were screened by the 

trained teachers. 555 (30.83%) schools could not be screened by the teachers 

due to the lack of manpower. However, the ophthalmic assistants screened 226 

schools of the left out ones. 

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A total of 3,19,903 students were screened. 28,317 (8.85%) students were detected 

to have some ocular problem, which corresponds well to the prevalence of 

ocular problems in Gujarat. This points to a good screening conducted by the 

teachers and the ophthalmic assistants. Out of these 28,317 students, majority, 

12,408 students (43.81%) were found to have refractory error. Hence, even 

today refractory error constitute the major cause of ocular morbidity amongst 

school children. 7750 (27.37%) students had minor ailments like conjunctivitis, 

vitamin A deficiency, colour blindness. 441 students were referred to higher 

centres for conditions like cataract, squint, congenital anomalies, ptosis etc. 

Rest 7718 (27.25%) students were false positive detections by the teachers. 

All the 12,408 students having refractory errors were given spectacles free 

of cost. Amongst the 441 students referred to higher centres, 25 (5.66%) had 

cataract, 288 (65.3%) had squint and 168 (38.1%) had congenital anomalies like 

ptosis, coloboma. 

In conclusion in every community children are the most important assets 

and future of nation lies in their hands. They must be at the very heart of 

“development”. Their well being, capabilities, knowledge and energy will 

determine the future of Nation as a whole. 

Globally, about 70 million blind person years are caused by childhood 

blindness. The major cause of ocular morbidity in school children is refractory 

error which is very much a preventable cause of blindness. Participation of 

school teachers and integration of ophthalmic assistants and ophthalmologists 

in the programme can work significantly to reduce the prevalence of childhood 

blindness. 

REFERENCES 

1. Vision screening in school children. Training module. Danish Assistance to the 

National Programme for Control of Blindness. New Delhi, India: 1. 

2. Role of optometry in vision 2020. Community eye health; vol 15, No 43; 2002, 35-36 

3. Gupta M, Gupta BP, Chauhan A, Bhardwaj A. Ocular morbidity prevalence among 

school children in Shimla, Himachal, North India. Indian J Ophthalmol 2009;57:133- 

8. 

4. Desai S, Desai R, Desai NC, Lohiya S, Bhargava G, Kumar K. School eye health 

appraisal. Indian J Ophthalmol 1989;37:173-5. 

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