Living with life-long high-UV exposure – what does this mean for the eye? And how can eye and vision care be provided in remote regions? A field trip to the Himalayas taught us two valuable lessons.
How can UV radiation damage the eye and sight over time? This is a question that is often debated by eye doctors and optometrists. The World Health Organization estimates that 20 percent of cataract cases are caused by exposure to UV radiation; photokeratitis, “sunburn” of the cornea, is also linked to UV. The fact that the sun and sports lenses have to provide eyeglass lens wearers with full UV protection is common knowledge. But a lot of UV radiation enters our eyes when we’re not wearing sun or sports glasses, in daily life, whenever the sun shines, on cloudy days, and when wearing clear lenses. The first question we need to find answers to is what life-long exposure to high UV radiation means for the eyes and for patients’ visual experience. In order to get valuable insights, it is essential to combine an ophthalmological eye exam with an eye test and interview patients about their life and work. For significant results, patients should live in a region where the UV index is constantly high.
More than 2 billion people around the world live in regions with no access to eye and vision care. That means a visit to the optician’s or an eye doctor is impossible due to remoteness and/or affordability. Furthermore, poor education and a lack of awareness about public health, good vision and eye health is missing across the board*. Given the importance of being able to see clearly, and preserving sight, as well as the need for comprehensive UV protection for eye health, the second issue we want to know more about is how to provide eye and vision care in remote areas, where the majority of population is living in poverty.
For field trips to the Himalayas in the Northern Indian state of Uttarakhand in April and June 2018, ZEISS, the ZEISS Vision Science Lab and the Aloka Vision Programme joined forces with the Department of Ophthalmology, Himalayan Institute of Medical Science, Swami Rama Himalayan University, Dehradun, and Parvitya Jan Kalyan Sansthan, a Dehradun-based non-governmental organization that is also committed to public health. The team of ophthalmologists and optometrists went to “the Hills” – as the Himalayas is also known – and screened more than 400 patients who have no access to eye and vision care and live under a constantly high UV index, which is extreme in the summer.
I often team up with students and optometrists from the institute to organize eye camps in the hills to screen patients for visual impairments like cataract or retina damage.Professor Renu Dhasmana, Himalayan Institute of Medical Science in Dehradun
“The challenge is to manage the logistics and perform hundreds of eye tests in a short time. I remember one day I had to screen about 700 people who were waiting in a queue.” Efficient eye test routines matter, as do capacities for getting patients from remote villages to a hospital so they can receive treatment. “The better we can establish quality eye and vision care in remote areas, the more people we can help using the available resources,” says Professor Dhasmana.
The eye exam and vision test used during the field trip were based on the Aloka Vision Programme standard and included an exam of the anterior and posterior of the eye, as well as a prescription for all those who need glasses. Professor Siegfried Wahl and Dr. Alexander Leube from the ZEISS Vision Science Lab at Tübingen University designed the study and were part of the team. Dr. Leube says: “We added two major steps to the usual eye camp routine of the Aloka Vision Programme. First, we integrated one-on-one interviews with every patient to explain the goals of the eye camp in detail, to obtain their full consent as well as background information on their education, life, work and medical status.” That was a real challenge as not everybody speaks Hindi. The interview therefore had to be conducted in the local language by volunteers from Parvitya Jan Kalyan Sansthan, or in Hindi by Aloka optometrists. “We then led focus groups to discuss awareness of UV, eye health and clear vision amongst the rural population.” The team believed it was important to comply with all ethical standards. “The collaboration with Professor Dhasmana, Dr. Shweta Sharma and Dr. Nishtha Yadav from the Himalayan Institute is an experience we are very grateful for, and one we will definitely not forget. Eye care in rural India is so different and much more challenging than it is in Europe. Working with them really broadened our professional horizon.”
The full results of the field survey will be published in due course by the ZEISS Vision Science Lab. To illustrate lesson #1, a summary of the eye exam and vision test results from one reference group with more than 100 patients may be sufficient. And lesson #1 is that a combination of ophthalmology and optometry is the best for patients, efficiency and public health. In this reference group of patients above 40 years of age, only one out of a hundred needed no vision or eye care. About 15 percent needed a further exam at the eye clinic, and 25 percent needed immediate eye surgery, e.g. due to cataract or pterygium. Everyone else needed glasses.
Conventional eye and vision care in unserved areas do not feature exams performed by doctors and optometrists. Usually people are either screened for eye diseases and referred to hospital for any treatment, or for refractive errors and prescribed a pair of glasses. A combined campaign for ophthalmic eye exams and vision care saves a lot of effort in terms of organization and logistics, and saves time for patients and data handling. But above all it means patients receive care, either through medical treatment or glasses, and are not sent away from an eye exam if they need glasses, or have a vision test that reveals a need for eye surgery. Patients don’t care if a doctor or an optometrist saves their sight or restores their vision. This gain in efficiency and patient satisfaction also makes sense from a public health perspective.
“What we know from conducting the Aloka Vision Programme, which is dedicated to establishing basic vision care in rural areas all over India, is that eye and vision care are a matter of trust,” explains Dr. Premjeeth Moodbidri, Aloka Programme manager. “It takes time to convince people to go for an eye exam and for them to see wearing a pair of glasses not as a stigma but as an improvement.” That’s why it’s so vital for the communities where eye camps are planned to involve locals and local volunteers. “Just imagine if you’d never visited an optician’s, you’d know very little about eye care. What would you do if optometrists you don’t know appeared in your community and offered you a vision test? You would very likely be suspicious.”
The real challenge comes after the eye camp: who cares if the glasses dispensed do not fit or get broken? That’s where a local contact matters, a person who can help you solve the problem. “That’s why the Aloka Vision Programme, together with local partners and entrepreneurs, works to establish reliable and permanent community-based service – for building trust, for raising awareness and for offering excellent service to patients.” The field trip to Uttarakhand – and all the preparation in the months leading up to it – was a starting point for establishing the Aloka Vision Programme in this Indian state.
Madan Joshi, Executive Director of Parvitya Jan Kalyan Sansthan who organized the eye camps during the field trip and mobilized the patients, added: “Campaigns for eye health and good vision are urgently needed in rural Uttarakhand. Most people have a very limited income or live below the poverty line. Nevertheless, they are often limited in their daily activities due to vision problems. This is very problematic for older day workers, and for myopic children who have difficulties at school. That’s why we’re happy to support dedicated campaigns like this one by ZEISS – it really helps hundreds of people to get better vision and thus facilitate their lives.”
The Himalayan Institute, ZEISS and the Aloka Vision Programme ensure that all patients attending an eye camp during the field trip get either free medical treatment or free glasses.
*Aloka consumer surveys in Karnataka and Kerala, 2014/15