A technological approach to “Reaching the Unreached” – Leveraging teleophthalmology services in Rural Gujarat

Purpose: Early detection of sight?threatening disorders by technological applications like teleophthalmology and prompt treatment can help decrease visual impairment. This study evaluated the role of teleophthalmology in underserved rural areas along with cost?saving estimates for the end user. Methods: A prospective, observational, cross?sectional hospital?based study was conducted over 3 months. First 1000 teleconsultations were included. None of the patients denied providing informed consent. The patients were consulted at the eight vision centers and three satellite centers of the hospital in the nearby rural and tribal regions closer to their residential places. These vision and satellite centers were connected to the base hospital like a hub and spoke model with a teleophthalmology network. Results: Cataract (n = 301, 30.1%) and refractive error (n = 290, 29%) were the most common diagnosis. 42.1% of patients were referred to base hospital for further evaluation. Thus, a total of 57.9% of patients were not required to visit the base hospital for initial consultation, saving time and money. Furthermore, 15.1% of patients were provided medical treatment at the vision center and satellite center, which helped in making teleophthalmology cost?saving for the patients. An average of Rs. 621/? were saved per patient for the community in our study. Conclusion: Networked teleophthalmology model can be an affordable and feasible tool for providing eye care delivery services in rural and tribal regions of Gujarat and the whole country, especially for the end user. Thus, it may be a workable model in ophthalmology practice with substantial cost saving to the community.

Current estimates of the economic burden of blindness and visual impairment in India: A cost of illness study

Purpose: Currently, there are an estimated 4.95 million blind persons and 70 million vision impaired persons in India, out of which 0.24 million are blind children. Early detection and treatment of the leading causes of blindness such as cataract are important in reducing the prevalence of blindness and vision impairment. There are significant developments in the field of blindness prevention, management, and control since the “Vision 2020: The right to sight” initiative. Very few studies have analyzed the cost of blindness at the population level. This study was undertaken to update the information on the economic burden of blindness and visual impairment in India based on the prevalence of blindness in India. We used secondary and publicly available data and a few assumptions for our estimations. Methods: We used gross national income (GNI), disability weights, and loss of productivity metrics to calculate the economic burden of blindness and vision impairment based on the “cost of illness” methodology. Results: The estimated net loss of GNI due to blindness in India is INR 845 billion (Int$ 38.4 billion), with a per capita loss of GNI per blind person of INR 170,624 (Int$ 7,756). The cumulative loss of GNI due to avoidable blindness in India is INR 11,778.6 billion (Int$ 535 billion). The cumulative loss of GNI due to blindness increased almost three times in the past two decades. The potential loss of productivity due to vision impairment is INR 646 billion (Int$ 29.4 billion). Conclusion: These estimates provide adequate information for budgetary allocation and will help advocate the need for accelerated adoption of all four strategies of integrated people?centered eye care (IPCEC). Early detection and treatment of blindness, especially among children, is very important in reducing the economic burden; thus, there is a need for integrating primary eye care horizontally with all levels of primary healthcare

Safety and efficacy of simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma.

PURPOSE: To establish the safety and efficacy of simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma. METHODS: We studied 109 consecutive patients who underwent planned simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma by a single surgeon from January 1990 through December 1999. The main outcome measures were postoperative intraocular pressure (IOP), corneal clarity and diameter, visual acuity, bleb characteristics, time of surgical failure and complications. Postoperative complications including endophthalmitis and anaesthetic morbidity and mortality were also analysed. RESULTS: The series consisted of 218 primary combined trabeculotomy-trabeculectomy surgeries during 109 anaesthesias. The mean follow-up period was 16.33 +/- 16.22 months. The IOP reduced from 26.4 +/- 5.9 mmHg to 13.5 +/- 4.5 mmHg, with a mean percentage reduction of 46.2 +/- 23.7 (P < 0.0001). The success (IOP < 16 mmHg) probabilities were 90.9%, 88.0% and 69.3% at first, second and third year respectively (Kaplan-Meier analysis). The success probability of 69.3% obtained at third year was maintained till 6 years of follow-up. One hundred and sixty six (76.1%) eyes had significant corneal oedema. Postoperatively, the cornea cleared in 93 (57.8%) eyes. Clinically, well functioning blebs were present in 114 of 171 eyes (66.6%). Postoperatively, 18 (8.3%) eyes developed shallow anterior chamber and 6 (33.3%) of them required surgical reformation. There was no incidence of endophthalmitis or any other sight-threatening complication. Of the anesthetic complications, apnea occurred in 17 (15.6%) patients and all were successfully resuscitated. The most serious post-anaesthetic complication was cardio-pulmonary arrest that occurred 5 hours postoperatively following aspiration during feeding in one child; this child could not be resuscitated. Two children had delayed recovery (2 and 4 hours respectively). The child who had delayed recovery by 2 hours survived and has completed 3 years of follow-up while the other child expired 48 hours later. CONCLUSION: Simultaneous bilateral primary combined trabeculotomy-trabeculectomy is safe and effective for developmental glaucoma. It obviates the need for long second anaesthesia with its attendant risks. It offers several other benefits to the patients and families.

Refresher training and continuing education for para-medical ophthalmic assistants.

This paper describes a refresher training and continuing education programme in clinical and community ophthalmology for para-medical ophthalmic assistants (PMOAs) conducted by the Lions Aravind Institute of Community Ophthalmology. The course participants included 60 PMOAs working either in district hospitals, primary health centres or mobile units from the districts in Maharashtra. Each training programme was spread over 43 hours in 4 days and included lectures, practical demonstrations, and hands-on training in the outpatient, inpatient, and operation theatre of the training institution. Participants were given exposure to outreach activities in an eye camp and a satellite eye centre resembling a district hospital. The PMOAs found the training to be useful and it was seen that areas like patient counselling, instrument and equipment maintenance, and assistance in the operation theatre for newer surgical procedures which were lacking in the basic training were fulfilled in this training programme. Regional Institutes of Ophthalmology, upgraded medical colleges, and other eye-care institutions which have facilities and manpower could organise similar refresher and continuing education programmes for PMOAs so that they could be utilised more efficiently in the blindness-control activities in the country.

Developing a model to reduce blindness in India: The International Centre for Advancement of Rural Eye Care.

With the continuing high magnitude of blindness in India, fresh approaches are needed to effectively deal with this burden on society. The International Centre for Advancement of Rural Eye Care (ICARE) has been established at the L.V. Prasad Eye Institute in Hyderabad to develop such an approach. This paper describes how ICARE functions to meet its objective. The three major functions of ICARE are design and implementation of rural eye-care centres, human resource development for eye care, and community eye-health planning. ICARE works with existing eye-care centres, as well as those being planned, in underserved areas of India and other parts of the developing world. The approach being developed by ICARE, along with its partners, to reduce blindness is that of comprehensive eye care with due emphasis on preventive, curative and rehabilitative aspects. This approach involves the community in which blindness is sought to be reduced by understanding how the people perceive eye health and the barriers to eye care, thereby enabling development of strategies to prevent blindness. Emphasis is placed on providing good-quality eye care with attention to reasonable infrastructure and equipment, developing a resource of adequately trained eye-care professionals of all cadres, developing a professional environment satisfactory for patients as well as eye-care providers, and the concept of good management and financial self-sustainability. Community-based rehabilitation of those with incurable blindness is also part of this approach. ICARE plans to work intensively with its partners and develop these concepts further, thereby effectively bringing into practice the concept of comprehensive eye care for the community in underserved parts of India, and later in other parts of the developing world. In addition, ICARE is involved in assessing the current situation regarding the various aspects of blindness through well-designed epidemiologic studies, and projecting the eye-care needs for the future with the help of reliable information. With balanced attention to infrastructure, manpower, financial self-sustenance, and future planning, ICARE intends to develop a practical model to effectively reduce blindness in India on a long-term basis.

Economic burden of blindness in India.

Economic analysis is one way to determine the allocation of scarce resources for health-care programs. The initial step in this process is to estimate in economic terms the burden of diseases and the benefit from interventions for prevention and treatment of these diseases. In this paper, the direct and indirect economic loss due to blindness in India is calculated on the basis of certain assumptions. The cost of treating cataract blindness in India is estimated at current prices. The economic burden of blindness in India for the year 1997 based on our assumptions is Rs. 159 billion (US$ 4.4 billion), and the cumulative loss over lifetime of the blind is Rs. 2,787 billion (US$ 77.4 billion). Childhood blindness accounts for 28.7% of this lifetime loss. The cost of treating all cases of cataract blindness in India is Rs. 5.3 billion (US$ 0.15 billion). Similar estimates for causes of blindness other than cataract have to be made in order to develop a comprehensive approach to deal with blindness in India.

Economic consequences of HIV/AIDS in India.

BACKGROUND: HIV/AIDS is one of the pressing public health problems in India. Available information indicates a rising trend of infection. The impact of HIV/AIDS on the economic front is important as it affects mainly the young, who are in the reproductive age group. We estimated the cost of productivity losses in a lifetime attributable to HIV-related mortality in India in the population of the year 1991 at current HIV infection rates. METHODS: The analysis was done from the societal viewpoint, adopting a discount rate of 5%. To estimate the loss in person-years due to HIV/AIDS, two scenarios were considered. Firstly, the population without HIV/AIDS, and secondly, the population with HIV/AIDS. The difference in person-years lived by the cohort in both populations would provide the person-years lost due to HIV/AIDS. To calculate the person-years lived in each, the life table approach was used. The demographic data from the 1991 Census were used. The population was divided into 15 five-year cohorts and the current age-specific death rates were used. Assumptions regarding HIV incidence rates in urban and rural areas in different age groups were made based on the available data and consensus of experts. The estimate was first done for a cohort of 100,000 population for rural and urban areas and then extrapolated to the population in the different age groups. To convert the person-years lost into monetary terms, minimum wages were estimated to be Rs 14,460 per annum. RESULTS: The total undiscounted life-years lost due to HIV/ AIDS by the present population of India will be 238.4 million years-123.7 million years for urban and 114.7 million years for rural areas. On an average this is 0.4 years lost per person. The life-years lost per case of HIV was 44.4 years. Assuming minimum wages of Rs 14460 as the value of one year, the total economic loss is Rs 3447 billion. The productivity loss per case is Rs 642,024 (US$ 20,710). For an estimated national per capita income of Rs 4252.4 the total economic loss is Rs 1014 billion. If a discount rate of 5% is applied for future losses then the total potential years of life lost will be 23 million-11.3 million for urban and 11.7 million for rural areas. In monetary terms this will be Rs 332.6 billion by minimum wages assumption, and 97.8 billion if the national per capita income is assumed to be the cost of one year. CONCLUSION: HIV/AIDS imposes a significant burden on the economic front. The productivity losses are likely to be an underestimate as the costs of treatment of HIV/AIDS patients, prevention programmes and labour costs have not been taken into account. To decide whether HIV/AIDS needs a high priority int he Indian context, it is necessary to have similar estimates for other important diseases such as tuberculosis and cancer.