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With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

Introduction: Primary health care in Tanzania is provided at two types of health units, the dispensary and the health centre. Theoretically, primary health workers (with knowledge of primary eye care [PEC]) are ideally placed to identify people in need of eye care services. In Tanzania, they are expected to be able to identify, treat, or correctly refer a number of eye conditions including cataract, trauma, presbyopia, and the 'red eye'. They are also expected to be able to measure visual acuity correctly and to educate the community about prevention., Objectives: The objective was to determine the effect of enhanced supervision of health workers on PEC knowledge and skills in Kilimanjaro Region, Tanzania., Study Design: This was a quasi-experimental, cluster randomized intervention study of an enhanced supervisory method compared to a routine supervisory method; 36 dispensaries were randomly allocated into the two groups., Participants: Health workers based at government dispensaries in Mwanga District., Data Collection: Participants were interviewed pre and post intervention and the information was recorded using a standardized pretested questionnaire., Results: Mean scores of knowledge in healthcare workers was higher in the intervention group (score = 6.43, 80.4% improvement) compared to the non-intervention group (score = 4.71, 58.9% improvement). The ability to describe and demonstrate vision testing was better (score = 1.8) in the enhanced supervision group compared to the routine supervision group (score = 0.88, P = 0.03). There was a high level of attrition (24%) within one year from the time of baseline survey, especially amongst clinical officers (44%)., Conclusion: During the pilot study, enhanced supervision improved PEC knowledge and skills of health workers compared to health workers with routine supervision., Recommendations: Training in PEC needs revision to become more practicum-based. There is need to revise supervision guidelines (to be skills-based) and the supervision skills of district eye coordinators (DECs) need to be enhanced. There is a huge need to improve governance (accountability and rule of law) of health staff., (Copyright © 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology., Methods: Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated., Results: Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2., Conclusions: In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.

Background: Knowledge and skills of primary health care workers (PHCWs) in primary eye care have been demonstrated to be inadequate in several districts of Kenya, Malawi, and Tanzania. We tested whether enhanced supervision, focused on improving practical skills over two years, would raise the scores of these workers on a test of basic knowledge and skills., Methods: This was a randomised controlled trial. All primary health care (PHC) facilities within two districts of each country were enrolled and randomly assigned by district (Kenya, Malawi) or by health care facility (Tanzania) to receive quarterly skills-based supervision by a district eye coordinator or to continue existing routine supervision. At baseline, a test of basic knowledge and skills in five key areas was administered to PHCWs, and visual acuity (VA) charts and working torches were provided. After two years the test was administered again. Changes in test scores were compared between the intervention (enhanced supervision) and the non-intervention (routine supervision) facilities., Results: All 137 facilities in the six districts were enrolled including 343 PHCWs. At baseline, no facility had a visual acuity chart and 18 (13%) had a working torch; the average total skills scores were 6.04 and 6.38 (maximum of 12) in the non-intervention and the intervention facilities, respectively. After two years, 16 intervention facilities (23.2%) had a visual acuity chart correctly placed and 19 (27.5%) had a working torch, compared to 4 (5.9%) and 6 (8.8%), respectively, in the routine supervision facilities. At the facility level, the change in overall test scores was +1.84 points in the intervention sites compared to +0.42 points in the non-intervention sites (p<0.001). Staff turnover included about 75% of the staff by the end of the study., Conclusion: The improvements in the enhanced supervision facilities were very modest and of questionable clinical significance. The low impact of the intervention may be due to the high turnover of PHCWs or high absenteeism. A better understanding of the quality of eye care at PHC facilities and influencing factors are urgently needed before continuing to invest resources in the scale up of this model of task shifting in Africa.

Background: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective., Methods: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework., Results: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care., Conclusion: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Objective: Assessment of a primary eye care programme in rural Rwanda over 2 years, with the aim of providing evidence to guide the development, training, supervision, or monitoring of primary eye care in Africa., Method: A comprehensive eye care programme in Rubavu District including a surgical service, health promotion, diagnostic and treatment services, training of health centre nurses and village health workers, and periodic visits by eye professionals to the health centres was implemented. Monitoring systems put in place from the beginning of the programme facilitated assessment of service use over 2 years., Results: A total of 6495 people received eye care services at eight health centres (3912 from nurses and 2583 from visiting eye professionals) and 149 Rubavu residents had surgery for cataract. Increases in service use in the first few months were not maintained over the 2-year period. The number of patients receiving surgery for cataract was less than half of the number referred for surgery., Conclusion: In this setting, initial increases in use of services at health centres were not maintained. Reasons varied and included the observation that VHW tend to refer patients to health centres only when there was a visiting eye professional. Reductions in visits to health centres could also be traced to changing government policies on medicines provided through insurance coverage. Increasing rates of referral and uptake of cataract surgery will require revising programme activities and adopting additional strategies.

Purpose: The World Health Organization and the International Agency for Prevention of Blindness recommends that there be 1 Child Eye Health Tertiary Facility (CEHTF) per 10 million people in developing countries. We sought to assess the current situation in Africa with regard to manpower, facilities, training, and output and to identify gaps in supportive services in CEHTFs., Methods: A survey was conducted by sending comprehensive questionnaires to all CEHTFs across Africa. Of the 27 CEHTFs in Africa, 21 (77.8%) returned forms., Results: Results show significant variability of resources (manpower, training, infrastructure, equipment, and refractive services). The mean population catchment area of the CEHTFs was 9.42 million. In 2007 the mean number of surgeries for congenital and developmental cataract, strabismus, and other conditions was 72.0, 37.1, and 169, respectively, with wide variation between the centers. Overall there were 1.26 operated boys for every girl. The mean surgical fee charged was US$117. The presence of a dedicated optometrist, childhood blindness coordinator, and a full-time anesthetist was associated with higher surgical output., Conclusions: Although the 21 CEHTFs cover an estimated population of 197 million, the number of children receiving services was generally low. Findings suggest that an additional 20 sub-Saharan countries are not large enough to support a CEHTF, and some large countries require additional facilities. Strengthening existing CEHTFs would require investment in manpower (especially support by optometrists and childhood blindness coordinators), programs to identify and refer children needing services, and internally and externally supported mechanisms to support the relatively high cost of providing this service.

Background: Little is known about the level of general public knowledge in Canada regarding the risk factors, prevention, and treatment of major blinding eye diseases., Methods: The study was a cross-sectional survey using self-administered questionnaires of patients presenting to 33 family practitioners' offices in British Columbia. We asked patients' opinions on the "value" of preventing blindness; the possibility of preventing cataract, glaucoma, and macular degeneration; the possibility of treating these conditions; and their knowledge of risk factors., Results: A total of 882 adults completed the questionnaires. Preventing vision loss was reported as one of 2 top health priorities in 28% of the questionnaires, more commonly by those with higher education and non-European ancestry. Overall, 69.2% reported familiarity with cataract as a cause of vision loss, 41.2% with glaucoma, and 20.2% with macular degeneration. Of these, 97.5% recognized the possibility of treatment for cataract, 91.5% for glaucoma, and 77.0% for macular degeneration, yet few respondents knew risk factors (amenable to intervention) for specific eye diseases. Men and younger respondents were more likely to report not knowing risk factors. Chinese-Canadians were least familiar with the association between smoking and cataract. Family history, probably the most important factor to help diagnose glaucoma, was recognized by only 23% of respondents., Interpretation: Although loss of vision was reported as a major medical concern, there is little understanding of the risk factors for different eye diseases. The association of non-European ancestry and low educational attainment with poor knowledge of eye diseases suggests that innovative education programmes in primary and secondary schools and in non-English languages are needed to improve knowledge, attitudes, and practices.

Aim: To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients during their 2 year, fixed duration, multidrug therapy (MDT)., Methods: Periodic eye examinations were conducted prospectively on a cohort of 301 consecutive newly diagnosed MB patients every 6 months during their 2 year course of MDT. Incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding at baseline., Results: 292 (97%) patients had one or more follow up visits. The incidence of lagophthalmos was 1.2%/patient year (95% CI 0.5% to 2.8%); corneal opacity was 7.4%/patient year (95% CI 5.1% to 10.6%); uveal involvement was 5.1%/patient year (95% CI 3.3% to 7.8%), and cataract that reduced vision to 6/18 or less was seen in 4.3%/patient year (95% CI 2.7% to 6.9%) of patients. Overall, 23 individuals (5.8%/patient year, 95% CI 3.9 to 8.8) developed leprosy related potentially blinding pathology during the 2 years of MDT., Conclusions: Approximately 20% of patients with MB leprosy can be expected to develop ocular complications of leprosy during a 2 year course of MDT, many (11%) of which are potentially vision threatening. Ophthalmological monitoring to detect and treat ocular complications at defined intervals during MDT is indicated.

Background: Public health officials of the Tibet Autonomous Region (TAR) of China requested a survey of blindness, eye diseases, and eye care service utilisation to assist the development of a 10 year blindness prevention and treatment plan. The objective of the survey was to determine the prevalence of blindness and visual impairment, as well as cataract surgical coverage and surgical outcome in the TAR., Methods: The Tibet Eye Care Assessment was a cross sectional prevalence study of three of the seven prefectures (provinces) of the TAR (Lhoka, Nakchu, and Lingzhr) selected to represent its three main environmental regions. The survey sample was selected using a random multistage cluster method. Two teams conducted the survey in a standardised fashion in each prefecture, Lhoka during May and Nakchu during June 1999, and Lingzhr during May 2000. Visual acuity, cause of vision loss, trachoma, and vitamin A deficiency were included in the clinical examination., Results: Among the 15,900 people enumerated, 12,644 were examined for an overall response rate of 79.6%. The crude prevalence of blindness (presenting better eye visual acuity of less than 6/60) was 2.3%; age and sex adjusted blindness prevalence was 1.4% (95% CI 1.3 to 1.5). Visual impairment (better eye presenting visual acuity of 6/24 to 6/60) was found in 10.9% (95% CI 10.5 to 11.2) of the population (age and sex adjusted). Cataract was the primary cause of blindness (50.7%), followed by macular degeneration (12.7%) and corneal opacity (9.7%)., Conclusion: Blindness is a serious public health problem in Tibet, with prevalence higher than in similar studies in eastern China. As elsewhere in the world, women have an excess burden of blindness compared to men. About 75% of blindness in Tibet can be either prevented or treated. Eye care planning for Tibet must focus on cataract, particularly among women.

Existing prevalence surveys do not provide adequate information to estimate the magnitude of ocular pathology or vision loss in leprosy patients. We sought to determine the prevalence of ocular findings and related risk factors in leprosy patients at the time of their disease diagnosis. We also sought to determine if there were geographic differences and whether these were due to different demographic characteristics of the populations. The study was undertaken at Schieffelin Leprosy Research & Training Centre (Karigiri, India), Leonard Wood Memorial Leprosy Institute (Cebu, Philippines), and (for 3 years only) ALERT (Addis Ababa, Ethiopia). Newly diagnosed multibacillary (MB) leprosy patients as well as MB cases relapsed after dapsone monotherapy were eligible for enrollment. In each study site, the target population was 300. Standardized examinations were conducted between 1991 and 1998. Patient enrollment included 301 patients in Karigiri, 289 patients in Cebu, and 101 patients in Addis Ababa. The age-adjusted prevalence of blindness (< 6/60 in the better eye) and visual impairment (6/24-6/60) was 2.8% and 5.2%, respectively. Lagophthalmos and leprosy related uveal changes were detected in 3.3% (95% CI 2.0-4.7%) and 4.1% (95% CI 2.4-5.7) of patients, respectively. Overall, 11% (95% CI 8.5-13.2%) of newly enrolled MB patients had potentially blinding leprosy related ocular pathology. Lagophthalmos was associated with increasing age, a short duration between onset and diagnosis, and a previous reaction involving the face. Uveal conditions were associated with increasing age. Overall, eye disease was more common in Indian and Ethiopian patients compared to Filipino patients; however, differences were not significant when controlling for age and clinical (non-ocular) factors. Patients with potentially blinding leprosy related pathology were over three times more likely to have other (hand and foot) disabilities than patients without pathology. Differences in the prevalence of blindness and potentially blinding leprosy related ocular pathology between the sites could be accounted for by the differences in age and other clinical factors of the patients at the different sites. Findings suggest that, even in the face of active leprosy control efforts, around 11% of patients will have potentially blinding pathology at the time of their diagnosis and 2.8% will be blind. If those patients with lagophthalmos or blindness are considered appropriate for referral for more detailed assessment, approximately 4% of newly diagnosed leprosy patients will require active follow-up for eye care; including those with reaction involving the face will result in 9.4% of patients requiring active follow-up. These people are likely to be older, with a reaction involving the face, and/or with other disabilities than those not requiring active follow-up.

Many African traditional healers provide treatment for eye diseases, yet there is little published information about eye care knowledge and practices among these healers; the information is necessary for the development of collaborative eye care activities with healers. Focus group discussions, in-depth interviews, and a representative sample survey of 107 randomly selected traditional healers in Chikwawa District, Malawi were conducted regarding eye care knowledge and practices. In the survey 68% of healers treated at least one of six common eye conditions. The most common eye condition treated by healers was cataract, followed by conjunctivitis/inflammatory trachoma. The size of the healer's practice, literacy, and great distance to a health facility were positively associated with the provision of eye care. Traditional healers have considerably more eye care interactions with the rural population than existing biomedical health personnel in Chikwawa District. Interviews revealed that most healers were aware of the availability of treatment for common eye conditions at biomedical health facilities and were interested in collaborating with existing biomedical eye care providers. We subsequently developed a collaborative eye care programme with healers in the district and report on early findings. Collaboration with healers in eye care programmes is advocated and recommendations are provided.

Little attention has been directed to the development, management and evaluation of eye care programmes for leprosy patients. This paper examines when an eye care programme for leprosy patients is needed, methods for integrating eye care into leprosy control programmes and lists of available ocular leprosy teaching materials.

Reported are the results of a primary eye care training programme for community-based leprosy control workers in the Republic of Korea. The 20-hour programme emphasized the detection and management of lagophthalmos (and its complications) and chronic iridocyclitis. Leprosy patients in four resettlement villages were examined independently by the health workers and an ophthalmologist. Agreement between the health workers and the ophthalmologist was good for the detection of most signs (lagophthalmos, acute iridocyclitis, and chronic iridocyclitis). Based on these preliminary results it is recommended that primary eye care be included as a part of the training for leprosy paramedical workers.

We examined 241 leprosy patients and 135 age-matched healthy controls in central South Korea, measuring intraocular pressure in the supine and the upright positions and measuring the size of the pupils in darkness as an indication of ocular autonomic dysfunction. The mean intraocular pressure was significantly lower in the patients and the mean size of pupils was significantly smaller in the patients than in the controls. However, there was no correlation between pupil size and intraocular pressure in our patients. Our findings show that leprosy patients have ocular autonomic dysfunction, but do not support previous speculation that this dysfunction is the primary cause for low intraocular pressure in leprosy.

A comprehensive review of all ocular surveys (40) of leprosy patients was undertaken. These surveys do not provide adequate information for defining the incidence or prevalence of ocular disease caused by Mycobacterium leprae. Furthermore, the level of disability and blindness from leprosy has not been addressed. The primary methodologic problems in these surveys are: a) lack of survey sampling techniques, b) institution-based or. clinic-based populations as the study population, c) inadequate instruments for the detection of clinical signs, d) non-ophthalmically trained individuals as examiners, e) definition of "ocular" disease that includes non-ocular conditions, f) failure to analyze by disease type, and g) failure to analyze by duration of disease or therapy. All of these studies were cross-sectional in nature. While this type of study is beneficial to health administrators for prioritizing eye care in health planning, a longitudinal study is required to investigate the risk factors for ocular involvement and blindness in these patients.

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