P bli H lth O hth l Public Health Ophthalmology l P Prevention - PowerPoint PPT Presentation

Community ophthalmology y p gy 4 groups of blindness community control programs g p y p g 1. Priority&majority highly cost- effective intervention Cataract & significant refractive error (50-67%) Cataract & significant refractive error (50 67%) 2. Focal blinding disease cost-effective, prevention&treatment Trachoma, Vitamin A deficiency etc (10-15%) Trachoma, Vitamin A deficiency etc (10 15%) Primary health care & community eye worker training 3. Complicated disease effective early treatment (by specialist) 3. Complicated disease effective early treatment (by specialist) Glaucoma, Diabetic retinopathy etc (20%) community screening program & referral system community screening program & referral system 4. Blinding disease no effective prevention&treatment aged related macular degeneration, retinitis pigmentosa aged e ated acu a dege e at o , et t s p g e tosa congenital ocular abnormalities

Community ophthalmology y p gy Blinding eye diseases CATARACT TRACHOMA GLAUCOMA ONCOCERCIASIS DIABETIC RETINOPATHY DIABETIC RETINOPATHY VITAMIN A DEFICIENCY VITAMIN A DEFICIENCY Focal disease Occur everywhere affect community affect community affect individual affect individual start in children affect mainly adult requires medicine equ es ed c e requires surgery requires surgery does not requires an eye doctor need an eye doctor HOSPITAL BASE COMMUNITY BASE

Screening Community ophthalmology y p gy Primary eye care in the community Simple Medication Simple Medication Screening Screening Health voluntier Health voluntier P i Primary care hospital h it l Simple Medication Midlevel health personel & treatment Academic support Case refer Midlevel health Midl l h lth Seconary care hospital Simple Surgery personel Ophthalmologist Ophthalmologist Research Research Case refer Academic support pp Complicated Surgery Tertiary care hospital Research Research Resident Subspecialty Ophthamologist Policy setting

Community ophthalmology y p gy Comprehensive Eye Care Comprehensive Eye Care Provincial Hos Pr Prov Provincial ovin incial al Hosp Hospit Hospit ital ital al Planning & Planning & Curat rative S ve Servi rvices es Management Eye Un Ey e Unit Comm Communi unity Hos Hospital P i P i Primar mary Car C are e Unit U i Co Comm mmuni unity Pr Prevention evention & & Pr Promotion omotion Dec 08 Phnom Penh 17

Community ophthalmology y p gy 1998 ประชากร จักษุแพทย อัตราสวน กทม ./ ปริมณฑล 8,619,340 290 29,722 ภาคกลาง 8 928 252 82 108 882 ภาคกลาง 8,928,252 82 108,882 ภาคตะวันออก 4,180,837 34 122,966 ภาคใต 8,696,590 49 177,481 ใ  ภาคเหนือ 10,048,976 53 189,603 ภาคเหนอ 10,048,976 53 189,603 ภาคอีสาน 21,404,751 60 356,746

Distribution of ophthamologist in Thailand Community ophthalmology y p gy Survey in 2007 63m population 803 ophthalmologist area ophthalmologist ratio gov pri total Bangkok 244 129 373 1:15171 Central 93 18 111 1:101691 Eastern Eastern 42 9 51 42 9 51 1:73230 1:73230 Southern 66 12 78 1:98124 Northern 70 9 79 1:136781 Northeastern 91 10 101 1:211169 Total 606 187 793 1:78711

Community ophthalmology y p gy Blind person years, four major condition condition estimated No ave. duration blind person years diti ti t d N d ti bli d cataract 25 x 5 = 125 1 glaucoma 8 x 8 = 64 3 DR 3 x 5 = 15 4 child blindness 1.5 x 50 = 75 2 140 25 120 20 100 15 80 60 10 40 5 5 20 0 0 cataract glaucoma DR child blindness cataract glaucoma DR child blindness

Community ophthalmology y p gy 6 step of problem solving paradigm 1. Define the problem 2 Measure the magnitude 2. Measure the magnitude 3. Define the key determination y 4. Decision of intervention 5. Set policy 6. Implement/evaluation

Community ophthalmology y p gy Key determination Biological factor genetic, age, microbiology, disease genetic, age, microbiology, disease Social/culture/behavior knowledge, fear, life style Environment/occupation Environment/occupation geographic, manpower, barrier

Community ophthalmology y p gy Health system evaluation Equity/Equality Quality Quality Efficiency Social acceptance Relevant

Important things are not visible to the eye . p g y By a Fox (in “ Little Prince ” ) All the lonely people, y p p , where do they come from? All the lonely people, where do they belong? where do they belong? “ Eleanor Rigby ” ( I can ) change the world ( I can ) change the world. E. Clapton

Community ophthalmology y p gy problem solving paradigm for blinding cataract 1. Define the problem What is blinding cataract? 2. Measure the magnitude How many blinding catract 2. Measure the magnitude How many blinding catract are there in Thailand? 3. Define the key determination What is the risk? 4. Decision of intervention What will we do? 5. Set policy How will we support it? 6. Implement/evaluation How does it work?

Community ophthalmology y p gy Blinding cataract Definition Definition Blinding 10/200 g Cataract lens opacity must R/O other cause of blindness Magnitude prevalence (backlock) incidence incidence

Community ophthalmology y p gy Key determination for cataract Biological factor age, disease(DM), trauma, congenital age, disease(DM), trauma, congenital Social/culture/behavior knowledge, attitude, life style, socioeconomic Environment/occupation Environment/occupation geographic, manpower, barrier, health system

Community ophthalmology y p gy Cataract Decision of intervention Screening of cases Screening of cases community base/hospital base health voluntier/health personel Referal system R f l routine/fast tract Operation satelite hospital/provincial hospital routine/campaign routine/campaign ECCE/PE with IOL

Community ophthalmology y p gy Cataract Decision of intervention Education Education mass media patient training personel i i l Follow up Ophthalmologist requirement ?

Community ophthalmology y p gy Strategies for finding the cataract blind 1. Wait for patients Surgical camp 2. Surgical camp in community 3. Screening clinic in community Screening clinic 4. Secondary surgical satellite hospital 4 S d i l t llit h it l Satellite hospital Community based referral 5. CBR case detection in community

Community ophthalmology y p gy Cataract policy setting Target setting Target setting waiting time blinding cataract operation rate blinding cataract operation rate Support doctor fee per case private/government equipment IOL manpower Ophthalmologist, nurse, personel, etc. p p g , , p , complication management special supporting group ? special supporting group ?

Community ophthalmology y p gy Cataract program implement & evaluation Registration/report waiting time blinding cataract operation rate register of blindness g Quality assurance good health care system good health care system audit O h ff Other effect other health care system personel

Community ophthalmology y p gy Ophthalmic screening (general) p g (g ) asymtomatic early/late damage asymtomatic early/late damage central/peripheral vision central/peripheral vision monocular/binocular monocular/binocular l o w l o w / h i g h / h i g h r i s k r i s k a g e a g e

Community ophthalmology y p gy Ophthalmic screening (special purpose) p g ( p p p ) student human right student human right driver/pilot safety driver/pilot safety worker efficiency worker efficiency etc etc.

Community ophthalmology y p gy Normal visual development intermittent fixation at birth nearby face fixation 2-3 month smooth follow near movement 3 month full accomodation 3-4 month onset of stereopsis 3-5 month well distant fixation 6 month subjective VA test 3 year adult-type VA test 5-6 year

Community ophthalmology y p gy VA for 6 month children C entering S teady S teady M aintain M aintain

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy High risk children g High risk adult g prematurity RD, severe ocular trauma prematurity RD, severe ocular trauma family Hx family Hx family Hx family Hx intrauterine infection one eye, age > 65 intrauterine infection one eye, age > 65 systemic disease systemic disease systemic disease systemic disease

Community ophthalmology y p gy มีค ๒๕๔๗ มีการติดเชื้อตาแดงใน neonatal ward ทานจะทําอยางไร

Community ophthalmology y p gy ๒๕๓๓ หยอด formalin ลงในตาเด็กแรกเกิด ๒๕๔๘ หยอด silver nitrate แลวมี severe ๒๕๔๘ หยอด silver nitrate แลวม severe reaction & corneal scar How do we do to solve this problem? p

Community ophthalmology y p gy Ophthalmia Neonatorum cause GC / Chlamydia /Chemical / Herpes simplex prophylacis 1% Silver nitrate (solution) 1% Tetracyclin / 0.5% Erythromycin (ointment) Providone iodine (solution) Providone iodine (solution) ceftriaxone 125mg Erythromycin base 50mg/kg/day x14 day

Community ophthalmology y p gy

Community ophthalmology y p gy Amblyopia y p refractive error / strabismus /other refractive error / strabismus /other 1-4 % in population occlusion therapy preschool age 4-6 year visual screening VA / stereopsis

Community ophthalmology y p gy

Community ophthalmology y p gy Amblyopic treatment

Community ophthalmology y p gy Xerophthalmia Vitamin A deficiency dry eye /corneal perforation Measle nutrition breast feeding immunization vitamin A supplement ? regular/ periodic

Community ophthalmology y p gy Keratomalacia bitot’s spot Keratomalacia bitot s spot

Community ophthalmology y p gy Trachoma chlamydial infection poor environment/water supply superimpose bacterial infection flies lid ulcer trichiasis / entropian corneal ulcer/ scar i i i i / i /

Community ophthalmology y p gy Trachoma Rx ineffective, long course, complication, cost topical tetracyclin / erythromycin bid x 5d/m x 6 month aim severity population control surgical correction of entropian

Community ophthalmology y p gy

Community ophthalmology y p gy Retinopathy of Prematurity p y y prematurity / oxygen therapy vasoconstriction neovascularization traction RD retrolental fibroplasia high risk group high risk group BW < 1500 gm GA < 32 week oxygen Rx > 4 hour

Community ophthalmology y p gy Retinopathy of Prematurity dilated fundus examination as soon as possible Threshold ROP stage 3 plus >3 hour cont. / 8 hour sum. Cryotherapy / laser treatment retinal surgery follow up look for high myopic astigmatism glaucoma follow up look for high myopic astigmatism, glaucoma amblyopic treatment amblyopic treatment

Community ophthalmology y p gy ROP 1 2 3 4 3 4

Community ophthalmology y p gy ROP

Community ophthalmology y p gy Glaucoma ocular hypertension increase IOP normal tension glaucoma optic nerve damage physiologic large cupping visual field defect POAG PACG SOAG SACG

Community ophthalmology y p gy Glaucoma Glaucoma Screening test Screening test IOP Schiotz / applanation tonometry optic nerve cupping non - stereopsis / stereopsis visual field confrontation / Goldman perimetry / CTVF

Community ophthalmology y p gy Glaucoma High risk group > 40 year old DM, thyroid HT IHD hi h HT, IHD high myopia i family history of POAG y s o y o O G angle recess glaucoma steroid induced glaucoma

Community ophthalmology y p gy normal

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy Goldman ‘s perimetry

Community ophthalmology y p gy CTVF

Community ophthalmology y p gy Retinal vascular disease Retinal vascular disease Diabetic retinopathy Diabetic retinopathy DM type1 5year after Dx DM type2 at time of Dx annually dilated fundus examination till Dx of DR

Community ophthalmology y p gy Diabetic retinopathy non - proliferative / proliferative lif ti / lif ti clinical significant macular edema ( CSME ) ? clinical significant macular edema ( CSME ) ? LASER Rx PMP PRP vitrectomy

Community ophthalmology y p gy

Community ophthalmology y p gy CSME CSME

Community ophthalmology y p gy Aged macular degeneration Aged macular degeneration central scotoma blur vision metamorphopsia central scotoma blur vision metamorphopsia non - exudative / exudative screening test Amsler’s grid nutritional support? LASER Rx stop smoking

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy Ocular trauma workplace recreation/sport home transportation protective device environment law individual screening test

Community ophthalmology y p gy

Community ophthalmology y p gy Disorder change in anatomy/physiology of an organ system organ system Impairment functional change in organ system Disability skill / ability of the individual Handicap the societal/economic consequence of a disability disability

Community ophthalmology y p gy • the organ the person disorder impairment disability handicap anatomical change functional change skill /ability social /economic o c c ge u c o c ge s / b y soc /eco o c inflammation visual acuity reading extraeffort atrophy visaul field daily living dependence scar color vision mobility

Community ophthalmology y p gy Disorder Impairment Disability Handicap Medical/surgical Visual aids Social intervention training training intervention intervention adapted equipment adapted equipment counseling education education

Community ophthalmology y p gy Visual rehabilitation medical visual aid orientation/mobility training y g educational blind/low vision special school p social behavior, recreation, sex etc , , occupational p

Community ophthalmology y p gy Visual field orientation / mobility Visual field orientation / mobility 51-70 degree normal 31-50 degree normal, use more scanning 11 30 degree 11-30 degree near normal, constant scanning near-normal, constant scanning 6 -10 degree slower, require scanning & cane 3 - 5 degree use cane for detection ,vision for identification less unreliable, use blind mobility skill NLP NLP no visual orientation no visual orientation

Community ophthalmology y p gy mobility training t traveling vision 3/200 with > 50 degree VF li i i 3/200 ith 50 d VF < 20 degree VF orientation problem < 20 degree VF orientation problem 1) sight guide 2) long cane 3) dog guide 4) electronic mobility device 4) electronic mobility device

ู   ็  ู Community ophthalmology y p gy การนําทางคนตาบอด ๑ ) ผูนําทาง หุบแขนขางลําตัว งอขอศอกเล็กนอย  ํ ํ ั ๒ ) ผตาม ใชมือจับที่เหนือขอศอก หางผนํา๑ / ๒กาว ๒ ) ผูตาม ใชมอจบทเหนอขอศอก หางผูนา๑ / ๒กาว ๓ ) ผูนําทาง เดินพอใหผูตาม สามารถเดินตามทันได ๔ ) ผูนําทาง ขยับขอศอกไปดานหลัง เพื่อเปนสัญญาณ วา ทางแคบลง มีปร ต วา ทางแคบลง มประตู ๕ ) ผนําทาง คอยบอกวามีสิ่งสังเกตที่สําคัญ อยที่ใด ๕ ) ผูนาทาง คอยบอกวามสงสงเกตทสาคญ อยูทใด ๖ ) เมื่อจะปลอยใหผูตามอยูตามลําพัง ควรไวที่ติดเกาอี้ หรือ กําแพง

Community ophthalmology y p gy Cane long cane foot to 1 1/2 inch above sternum bottom contact feed back scanning no forewarning of overhead obstacles no forewarning of overhead obstacles white cane sign of visual impairment g p

Community ophthalmology y p gy dog guide extensive training maturity & intelligence age 18 -60, good health, good hearing and no 18 60 d h lth d h i d residual vision German shepherd, Golden/Labrador retriever and Boxer F Female dogs are preferred. l d f d

Community ophthalmology y p gy Low vision care 1) diagnosis 2) 2) medical & surgical treatment di l & i l t t t 3) analysis of visual function 3) ys s o v su u c o 4) problem discussion 5) low vision examination 6) 6) psychosocial assessment h i l 7) provision of a range of equipment 7) provision of a range of equipment

Community ophthalmology y p gy low vision care 8) 8) recommendation & instruction of optical device d ti & i t ti f ti l d i 9) prescription 9) prescription 10) dispensing 11) patient education 12) vision & other rehabilitation service 13) access to available funding sources 13) access to available funding sources 14) continuing eye care 15) training & continuous education

Community ophthalmology y p gy Range of VA reading ability general ability 20/12 - 20/25 normal normal c reserve 20/30 - 20/60 shorter distance normal s reserve 20/80 - 20/160 near - normal near normal require aids 20/80 - 20/160 near - normal near normal require aids 20/200 -20/400 slower than normal slower than normal 20/500 -20/1000 limited reading some task c aids 20/1250 20/2500 20/1250 -20/2500 unreliable few task, use substitute li bl f k b i NLP not possible no task p

Community ophthalmology y p gy adaptive low vision device 1) relative size device 2) light/illumination control ) i /i i i 3) posture/positioning device 3) posture/positioning device 4) writing /communication device 5) medical assistive device 6) mobility assistive device 7) sensory substitution device 7) sensory substitution device

Community ophthalmology y p gy sensory substitution device A dit Auditory substitute b tit t talking book/device, computer program etc. talking book/device, computer program etc. Tactile substitute Braille, Nonbraille Vision substitute neural prosthesis neural prosthesis

Community ophthalmology y p gy Braille 6 raised dot 3 high / 2 wide 6 raised dot 3 high / 2 wide grade 1 letter g grade 2 contraction/abbreviated word grade 3 personal note taking b tt l better learning in children i i hild 100 word/ min but talking book 175 word/min 100 word/ min but talking book 175 word/min

Community ophthalmology y p gy Optical aids Hand-held magnifiers Stand magnifiers Ill Illuminated magnifiers Reading glasses i t d ifi R di l Loupes and visors Reading telescopes oupes d v so s e d g e escopes Telescopes Video magnifiers Prisms Reverse telescopes

Community ophthalmology y p gy Hand - held magnifiers inexpensive / familiar / easy to use normal working distance must be held steadily at an exact distance i i limited viewing field make slow reading limited viewing field make slow reading