AMERICAN JOURNAL OF OPHTHALMOLOGY FRANK
W.
NEWELL,
Editor-in-Chief
233 East Ontario St., Chicago, Illinois 60611 EDITORIAL BOARD Mathea R. Allansmith, Boston Douglas R. Anderson, Miami Crowell Beard, San Jose Bernard Becker, St. Louis Benjamin F . Boyd, Panama Charles J. Campbell, New York Ronald E. Carr, New York Thomas Chalkley, Chicago Claes H. Dohlman, Boston Fred Ederer, Bethesda DuPont Guerry III, Richmond
Published
Arnall Patz, Baltimore Paul Henkind, Bronx Steven M. Podos, New York Robert W. Hollenhorst, Rochester Albert M. Potts, Louisville Herbert E. Kaufman, New Orleans Algernon B. Reese, New York Arthur H. Keeney, Louisville Robert D. Reinecke, Albany Bertha A. Klien, Tucson Marvin L. Sears, New Haven Carl Kupfer, Bethesda David Shoch, Chicago Irving H. Leopold, Irvine Bruce E. Spivey, San Francisco A. Edward Maumenee, Baltimore Bradley R. Straatsma, Los Angeles Irene H. Maumenee, Baltimore Gunter K. von Noorden, Houston Edward W. D. Norton, Miami G. Richard O'Connor, San Francisco
monthly by the Ophthalmic
Publishing
Tribune Tower, 435 North Michigan Avenue, Chicago, Illinois
Company 60611
Directors: A. E D W A R D M A U M E N E E , President; D A V I D S H O C H , Vice President; F R A N K W. N E W E L L , Secretary and Treasurer; E D W A R D W. D. N O R T O N , B R U C E E. SPIVEY, B R A D L E Y R. STRAATSMA
NEW INITIATIVES IN T H E WAR ON BLINDNESS The year 1978 marked a turning point in the war on blindness. After years of discussion and planning t h e World Health Organization (WHO) launched its Program for the Prevention of Blindness, and the International Agency for the Pre vention of Blindness (IAPB), WHO's nongovernmental helpmate, convened its first General Assembly. These events came none too soon. Ad mittedly fragmentary data suggest 40 mil lion people, 1% of the human race, are blind. 1 The cost, in social services, lost productivity, and human suffering is incalculable—especially since the great est burden falls on developing countries, which can least afford it. Blindness rates in trachoma and onchocerciasis endemic areas are commonly four to 20 times that of the West. Millions of India's citizens require cataract surgery; hundreds of thousands of Asian children are blinded and die each year with xerophthalmia. It is toward this excess of avoidable
blindness that W H O and IAPB have properly directed their attention. The goal is to reduce national blindness rates to below 0.5%, and more ambitiously, rates of even the worst affected communities to below 1%.2 Following the recommenda tion of an earlier Study Group, 3 blindness is being defined as vision less than 3/60 (unable to count fingers at 3 feet).4 By the very nature of the problem these goals are long term. The number of indi viduals already blind from xerophthal mia, trachoma, and onchocerciasis can decrease, and prevalence rates decline, only through aging and natural attrition. In the short run, effectiveness will be determined by the reduction in the num bers of new cases of disease and blind ness. WHO's new program is unique in pro viding a comprehensive, coordinated ap proach to the problem. T h e strategy is already clear: identify the major causes of blindness, their etiologic determinants and geographic distribution; provide in tensive intervention to the worst affected 103
104
AMERICAN JOURNAL OF OPHTHALMOLOGY
communities; and develop integrated programs for dealing with the root causes, as well as established cases of these dis eases. 4 Assessment will usually entail regional or national prevalence surveys. Intensive intervention can take many forms: mobile surgical programs for cataract and entropion; distribution of massive dose vita min A capsules for xerophthalmia, and the like. The thrust of the integrated pro grams is provision of eye services to tradi tionally neglected rural and urban com munities. The primary health worker, often the only member of the health es tablishment to come in contact with a majority of the population, is ideally situ ated to recognize and treat early xeroph thalmia and trachoma, supervise vitamin and antibiotic prophylaxis, encourage im proved dietary and hygienic practices, and recognize and refer patients in need of more sophisticated medical treatment or surgery to nearby secondary facilities. Tertiary facilities, traditional teaching hospitals with their complex, expensive equipment and western orientation have traditionally undercut these goals, by consuming a disproportionate share of available (and limited) funds and talent to provide highly sophisticated care to a tiny, privileged minority. Under the new scheme they will continue to provide high quality ophthalmic education, but to gether with training in nutrition, epidemi ology, demography, and public health, so as to produce professionals better suited for developing and implementing new, community-oriented programs. WHO's resources are limited. To a great degree initiative and financing must come from within each country. The associa tion is playing a crucial role by encourag ing formation of "national societies," 52 of which are now allied with it (44 sent delegates to the first General Assembly held in Oxford, England, last July); pro viding these societies with guidance and
JANUARY, 1979
direction; and stimulating them to initiate programs, raise funds, and prod their gov ernments into action. Partially in response to these activities, wealthier countries are contributing to the emerging campaign: DANIDA, the Danish aid agency has provided $10 mil lion to India's program: President Carter has designated blindness prevention a major priority of United States overseas assistance programs; and voluntary agen cies, such as Helen Keller International, Royal Commonwealth Society for the Blind, and the International Eye Founda tion have undertaken major, new initia tives in this area. We can only hope this promising start will result in future better eye health around the world. A L F R E D SOMMER REFERENCES
1. Prevention of Blindness. Report of the advisory meeting on programme development, Geneva, Feb. 20-23, 1978. WHO, PBL/78.4, 1978. 2. Strategic Planning for the Prevention of Blind ness. Report of a Task Force, Woodstock, July 10-12, 1978. WHO, PBL/78.6, 1978. 3. The Prevention of Blindness. Report of a WHO Study Group. Tech. Rep. Ser. No. 518, Geneva, 1973. 4. Technical and Operational Approaches to the Prevention of Blindness. Report of a meeting. Asilomar, Oct. 8-13, 1978. In press.
CORRESPONDENCE Letters to the Editor must be typed double-spaced on 8V2 x 11-inch bond paper, with lV2-inch margins on all four sides, and limited in length to two man uscript pages.
Instillation of Eyedrops Editor: The instillation of eyedrops is a diffi cult technique for many patients to mas-
W.
NEWELL,
Editor-in-Chief
233 East Ontario St., Chicago, Illinois 60611 EDITORIAL BOARD Mathea R. Allansmith, Boston Douglas R. Anderson, Miami Crowell Beard, San Jose Bernard Becker, St. Louis Benjamin F . Boyd, Panama Charles J. Campbell, New York Ronald E. Carr, New York Thomas Chalkley, Chicago Claes H. Dohlman, Boston Fred Ederer, Bethesda DuPont Guerry III, Richmond
Published
Arnall Patz, Baltimore Paul Henkind, Bronx Steven M. Podos, New York Robert W. Hollenhorst, Rochester Albert M. Potts, Louisville Herbert E. Kaufman, New Orleans Algernon B. Reese, New York Arthur H. Keeney, Louisville Robert D. Reinecke, Albany Bertha A. Klien, Tucson Marvin L. Sears, New Haven Carl Kupfer, Bethesda David Shoch, Chicago Irving H. Leopold, Irvine Bruce E. Spivey, San Francisco A. Edward Maumenee, Baltimore Bradley R. Straatsma, Los Angeles Irene H. Maumenee, Baltimore Gunter K. von Noorden, Houston Edward W. D. Norton, Miami G. Richard O'Connor, San Francisco
monthly by the Ophthalmic
Publishing
Tribune Tower, 435 North Michigan Avenue, Chicago, Illinois
Company 60611
Directors: A. E D W A R D M A U M E N E E , President; D A V I D S H O C H , Vice President; F R A N K W. N E W E L L , Secretary and Treasurer; E D W A R D W. D. N O R T O N , B R U C E E. SPIVEY, B R A D L E Y R. STRAATSMA
NEW INITIATIVES IN T H E WAR ON BLINDNESS The year 1978 marked a turning point in the war on blindness. After years of discussion and planning t h e World Health Organization (WHO) launched its Program for the Prevention of Blindness, and the International Agency for the Pre vention of Blindness (IAPB), WHO's nongovernmental helpmate, convened its first General Assembly. These events came none too soon. Ad mittedly fragmentary data suggest 40 mil lion people, 1% of the human race, are blind. 1 The cost, in social services, lost productivity, and human suffering is incalculable—especially since the great est burden falls on developing countries, which can least afford it. Blindness rates in trachoma and onchocerciasis endemic areas are commonly four to 20 times that of the West. Millions of India's citizens require cataract surgery; hundreds of thousands of Asian children are blinded and die each year with xerophthalmia. It is toward this excess of avoidable
blindness that W H O and IAPB have properly directed their attention. The goal is to reduce national blindness rates to below 0.5%, and more ambitiously, rates of even the worst affected communities to below 1%.2 Following the recommenda tion of an earlier Study Group, 3 blindness is being defined as vision less than 3/60 (unable to count fingers at 3 feet).4 By the very nature of the problem these goals are long term. The number of indi viduals already blind from xerophthal mia, trachoma, and onchocerciasis can decrease, and prevalence rates decline, only through aging and natural attrition. In the short run, effectiveness will be determined by the reduction in the num bers of new cases of disease and blind ness. WHO's new program is unique in pro viding a comprehensive, coordinated ap proach to the problem. T h e strategy is already clear: identify the major causes of blindness, their etiologic determinants and geographic distribution; provide in tensive intervention to the worst affected 103
104
AMERICAN JOURNAL OF OPHTHALMOLOGY
communities; and develop integrated programs for dealing with the root causes, as well as established cases of these dis eases. 4 Assessment will usually entail regional or national prevalence surveys. Intensive intervention can take many forms: mobile surgical programs for cataract and entropion; distribution of massive dose vita min A capsules for xerophthalmia, and the like. The thrust of the integrated pro grams is provision of eye services to tradi tionally neglected rural and urban com munities. The primary health worker, often the only member of the health es tablishment to come in contact with a majority of the population, is ideally situ ated to recognize and treat early xeroph thalmia and trachoma, supervise vitamin and antibiotic prophylaxis, encourage im proved dietary and hygienic practices, and recognize and refer patients in need of more sophisticated medical treatment or surgery to nearby secondary facilities. Tertiary facilities, traditional teaching hospitals with their complex, expensive equipment and western orientation have traditionally undercut these goals, by consuming a disproportionate share of available (and limited) funds and talent to provide highly sophisticated care to a tiny, privileged minority. Under the new scheme they will continue to provide high quality ophthalmic education, but to gether with training in nutrition, epidemi ology, demography, and public health, so as to produce professionals better suited for developing and implementing new, community-oriented programs. WHO's resources are limited. To a great degree initiative and financing must come from within each country. The associa tion is playing a crucial role by encourag ing formation of "national societies," 52 of which are now allied with it (44 sent delegates to the first General Assembly held in Oxford, England, last July); pro viding these societies with guidance and
JANUARY, 1979
direction; and stimulating them to initiate programs, raise funds, and prod their gov ernments into action. Partially in response to these activities, wealthier countries are contributing to the emerging campaign: DANIDA, the Danish aid agency has provided $10 mil lion to India's program: President Carter has designated blindness prevention a major priority of United States overseas assistance programs; and voluntary agen cies, such as Helen Keller International, Royal Commonwealth Society for the Blind, and the International Eye Founda tion have undertaken major, new initia tives in this area. We can only hope this promising start will result in future better eye health around the world. A L F R E D SOMMER REFERENCES
1. Prevention of Blindness. Report of the advisory meeting on programme development, Geneva, Feb. 20-23, 1978. WHO, PBL/78.4, 1978. 2. Strategic Planning for the Prevention of Blind ness. Report of a Task Force, Woodstock, July 10-12, 1978. WHO, PBL/78.6, 1978. 3. The Prevention of Blindness. Report of a WHO Study Group. Tech. Rep. Ser. No. 518, Geneva, 1973. 4. Technical and Operational Approaches to the Prevention of Blindness. Report of a meeting. Asilomar, Oct. 8-13, 1978. In press.
CORRESPONDENCE Letters to the Editor must be typed double-spaced on 8V2 x 11-inch bond paper, with lV2-inch margins on all four sides, and limited in length to two man uscript pages.
Instillation of Eyedrops Editor: The instillation of eyedrops is a diffi cult technique for many patients to mas-
