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Profile of low vision clinics in
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retrospective study
Article in British Journal of Visual Impairment · September 2011
DOI: 10.1177/0264619611414990
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British Journal
of Visual Impairment
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Profile of low vision clinics in eastern region of Nepal : A retrospective study
Ajit Kumar Thakur, Purushottam Joshi, Himal Kandel and Subhash Bhatta
British Journal of Visual Impairment 2011 29: 215
DOI: 10.1177/0264619611414990
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Profile of low vision clinics in
eastern region of Nepal
BJVI
A retrospective study
AJIT KUMAR THAKUR
PURUSHOTTAM JOSHI
HIMAL KANDEL
THE BRITISH
JOURNAL OF
VISUAL
IMPAIRMENT
Copyright © 2011 Authors
(Los Angeles, London, New Delhi,
Singapore and Washington DC)
Vol 29(3): 215–226
DOI: 10.1177/0264619611414990
RESEARCH REPORT
Mechi Eye Hospital, Anarmani-7, Jhapa, Nepal
Mechi Eye Hospital, Anarmani-7, Jhapa, Nepal
Institute of Medicine, Maharajgunj, Kathmandu Nepal
SUBHASH BHATTA
Institute of Medicine, Maharajgunj, Kathmandu, Nepal
A B S T R AC T The entire low vision patients’ file that underwent
low vision examination in 2009 in two major eye hospitals was
retrospectively reviewed. Out of 1547 cases, 1140 (73.69%)
were male and 407 (26.31%) were female. The mean age of
presentation was 31.04 ± 20.63 years, of which 89.1 percent
were from a rural community, 39.10 percent had avoidable
blindness. Refractive error and amblyopia (24%) and retinitis
pigmentosa (22.4%) were the most common causes of low
vision. Refractive error and amblyopia (30.33%), retinitis
pigmentosa (29.03%) and age related macular degeneration
(ARMD) (36.5%) were the major causes of low vision in 0–15,
>15–60 and >60 years age group respectively. The number of
patients 1107 (71.55%) improved significantly with refractive
correction. Eighty-eight (5.68%) were prescribed telescopes. For
near vision, only 359 (23.2%) patients were prescribed magnifiers.
There was a significant improvement of functional vision after
provision of low vision devices, particularly for patients with
residual vision better than 20/1200.
avo i d a b l e b l i n d n e s s , c a u s e s o f l ow
v i s i o n , r e f r a c t i ve e r r o r, r e t i n i t i s p i g m e n t o s a ,
age related macular degeneration (ARMD)
K E Y WO R D S
A person with low vision is someone who has an impairment of visual
functioning despite treatment and/or standard refractive correction. The
World Health Organization (WHO) has classified the visual status of a
person in four categories (WHO, 2009):
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T H E B R I T I S H J O U R NA L O F V I S U A L I M PA I R M E N T 2 9 ( 3 )
• apersonhavingbestcorrectedvision,inbettereye,betterthanor
equal to 6/18 is said to have normal visual status;
• apersonwithbestcorrectedvision,inbettereye,<6/18to6/60is
said to have visual impairment;
• apersonhavingbestcorrectedvision,inbettereye,<6/60to3/60is
said to have severe visual impairment;
• apersonhavingvisualacuity<3/60issaidtobeblind.
Visually impaired people are those who have visual acuity of less than
6/18 to light perception and/or a visual field of less than 10° from the
point of fixation and who are using or are potentially able to use their
vision for planning and/or execution of a task (WHO, 1993). Globally,
about 314 million people are visually impaired and 45 million of them
are blind. However, correctable refractive error as a cause of visual
impairment is not included in that number, which implies that the actual
global magnitude of visual impairment is greater (Siddiqui, Bäckman and
Awan, 1997). Further, 75 percent of this visual impairment is estimated to
be avoidable (preventable or curable) (WHO, 2004). In 1999, the WHO
Prevention of Blindness Program launched ‘VISION 2020: The Right to
Sight Initiative’ with the objective of assisting member states in eliminating
avoidable blindness by the year 2020 (Thylefors, 1998). The global target
is to ultimately reduce blindness prevalence to less than 0.5 percent in all
countries, or less than 1.0 percent in any community (WHO, 2005).
Nearly 87 percent of the world’s blind people live in the developing
countries (Siddiqui et al., 1997). More than half of them live in Asia and
a vast majority of them are in rural communities (Nepal Facts and
Figures, 2010). Many reasons have been identified for the rising tide of
blindness and low vision. Prominent among them is the increase of the
world’s elderly population, particularly in developing countries.
Nepal is one of the poorest countries of Asia situated between India and
China. The prevalence of blindness is 0.84 per 100 inhabitants. Cataract
(66.8%) and its sequelae (5.3%) are the major causes of blindness.
Other causes are retinal disease (3.2%), glaucoma (3.2%), and trachoma
(3.2%). Of the total blind population, 92 percent live in rural areas
(Brilliant et al., 1988). The higher percentage of avoidable blindness
reflects the poor health access of the community due to poor health
education and poor financial conditions due to the political instability
(Nepal Facts and Figures, 2010). The prevalence of low vision is 1.0
percent as estimated by Nepal Netra Jyoti Sangh (NNJS), a leading NGO
in eye care in Nepal (NNJS, 2002). NNJS launched the National Low
Vision Program in Nepal in 2005 with the aim of helping people who
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have incurable eye conditions with some residual vision to make best
use of their vision. It also aims to bring them into the mainstream of
society by helping them to use the residual vision to the best possible
extent with the use of low vision devices. This program has given
priority to pick the low vision patients from the community. The focus
groups who were trained for low vision screening were school teachers,
Community based rehabilitation, and eye care personnel.
No nationwide study has been conducted in low vision to date. A report
from Lumbini, in the western part of the country, showed lens related
conditions (e.g. cataract and its sequel) as the main causes of low vision
(35.55%) followed by refractive errors/amblyopia (19.23%), retinitis
pigmentosa (7.24%) and other retinal causes (6.64%) (KC et al., 2007).
In a report from Kathmandu, the capital, situated in the central region
of the country, the major cause of low vision was diabetic retinopathy
(15.8%), followed by macular diseases (13.2%), age related macular
degeneration (10.5%), retinitis pigmentosa (9.6%) and amblyopia
(8.8%) (Paudel, Khadka and Sharma, 2005). Hence the distribution of
the causes for low vision in this country appears to vary significantly
from place to place. No data on low vision services has been published
from the eastern part of the country.
This study was aimed to determine the most common causes of low
vision in different age groups which would help in the national low
vision planning. This study also aimed at determining the improvement
of visual acuity after the provision of low vision services. This
information would give an idea about the status of the low vision
services in eastern Nepal. Hence, it would help in the planning of
newer programs to address the lacuna in the model of the current
service. It will also provide a guideline to develop low vision services
in other developing countries as well.
METHODOLOGY
A retrospective study was carried out in two major eye hospitals of
eastern Nepal: Sagarmatha Choudhary Eye Hospital, Lahan and Mechi
Eye Hospital, Jhapa. The medical records of all the cases who visited
these hospitals in the year 2008 and 2009 were reviewed. The data
included by whom they were referred, consisted of age, sex, profession,
education level, their chief visual demands and difficulties, presenting
distance and near visual acuity, visual acuity with refractive correction,
types of refractive error, visual acuity with low vision devices and their
preferences, and the most commonly prescribed low vision devices.
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T H E B R I T I S H J O U R NA L O F V I S U A L I M PA I R M E N T 2 9 ( 3 )
Distance visual acuity was recorded in logMAR unit and was converted
into Snellen fraction. Similarly near visual acuity was tested at their
working distance with preferred light conditions for reading and was
recorded in M notation. Objective and subjective refraction was carried
out in all cases. Proper refractive correction was prescribed in spectacle
form. A trial of telescopes was carried out for suitable patients, and the
visual acuity with telescopes was noted. Similarly, the near magnifiers
of appropriate magnification were tried, and the near visual acuity with
magnifiers was noted. Preference of magnifiers was also documented.
Data was recorded and analysed using SPSS 14 software.
RESULTS
Demographic distribution
The total number of low vision cases included in the study period was
1547, of which 1361 (87.98%) of cases were referred from the eye care
professionals, 134 (8.66%) were referred from school teachers, 42
(2.71%) were referred from Community based rehabilitation and 10
(0.65%) from eye camps and other medical personnel.
Out of 1547, 1140 (73.69%) were male and 407 (26.31%) were female.
The mean age of presentation was 31.04 ± 20.63 years ranging from
3–87 years. There were 501 (32.38%) patients in the 0–15 years age
group, 868 (56.10%) of patients were in the group >15–60 years
age group and 178 (11.52%) patients were in the group >60 years age
group. There were 1379 (89.1%) patients from rural communities and
only 168 (10.9%) patients were from urban society.
Causes of low vision
Out of 1547 cases presented to the low vision clinics, 605 (39.10%)
had avoidable causes for visual impairment. Out of 605, 485 (80.1%)
were preventable and 120 (19.90%) were curable.
The causes of low vision in patients attending the low vision clinics are
shown in Figure 1. Refractive error and amblyopia (24%) and retinitis
pigmentosa (22.4%) were most common causes of low vision. Other
causes were globe anomalies (9.57%), optic atrophy (8.9%), congenital
cataract (8.7%), heredo macular degeneration (7.69%), age related
macular degeneration (5.7%), corneal opacity (5.1%), nystagmus associated
with unknown causes (4.1%), glaucoma (2.2%), albinism (1.1%) and
others (1.2%).
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30%
25%
24%
22.40%
20%
15%
9.57%
10%
8.90% 7.75% 7.69%
5.70% 5.10%
5%
4%
2.20% 1.20% 1.09%
0%
Figure 1. Causes of low vision in patients attending low vision clinics.
Table 1. Table showing causes of low vision in different age groups.
Causes of
Low Vision
0–15 years
(n = 501)
>15–60
years
(n = 868)
Congenital
Cataract
Albinism
Globe anomaly
Corneal opacity
Glaucomatous
optic atrophy
Refractive
error and
Amblyopia
Macular
disease
(except AMD)
Nystagmus
associated
with unknown
causes
Optic atrophy
Retinitis
pigmentosa
ARMD
Others
59 (11.8%)
56 (6.45%)
5 (2.80)
10
76
40
3
7
69
31
24
0
3
8
8
(2%)
(15.1%)
(7.98%)
(0.59%)
(0.8%)
(7.94%)
(3.57%)
(2.76%)
>60 years
(n = 178)
Total
120 (7.75%)
(0%)
17 (1.09%)
(5.93%) 148 (9.56%)
(4.49%) 79 (5.1%)
(4.49%) 35 (2.26)
152(30.33%) 205 (23.61%) 14 (7.86%) 371 (23.98%)
14 (2.79%)
88 (10.13%) 17 (9.55%) 119 (7.69%)
36 (7.18%)
26 (2.99%)
1 (0.06%)
63 (4.07%)
38 (7.58%) 76 (8.75%) 24 (13.48%) 138 (8.92%)
70 (13.97%) 252 (29.03%) 25 (14.04%) 347 (22.43%)
0 (0%)
3 (0.59%)
23 (2.64%) 65 (36.51%) 88 (5.68%)
11 (1.26%) 8 (4.49%) 22 (1.42%)
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T H E B R I T I S H J O U R NA L O F V I S U A L I M PA I R M E N T 2 9 ( 3 )
In the 0–15 year age group, the most common causes of low vision
were refractive error and amblyopia (30.33%), retinitis pigmentosa
(13.97%) and globe anomalies (15.1%) and congenital cataract
(11.8%). Similarly, retinitis pigmentosa (29.03%), refractive error and
amblyopia (23.61%) and heredo macular degenerations (10.13%)
were the most common causes of low vision in >15–60 years. Age
related macular degeneration (36.5%), retinitis pigmentosa (14.04%)
and optic atrophy (13.48%) were the most common causes in the age
group >60 years.
Visual status
Out of 1547 low vision patients, 819 (52.9%) were bilaterally blind and
only 725 (47.1%) had residual vision better than 3/60 in the better eye.
Out of 725, 418 (57.66%) were visually impaired and 307 (32.34%)
were with severe visual impairment according to WHO classification of
visual status (WHO, 2009).
Low vision services
The chief visual complaints for distance were recognizing faces
(n = 1195) and reading the chalk board letter (n = 435). For near, the
chief visual demands were reading print (n = 678) and coin identification
(n =171). Other visual problems included mobility problem (n = 314),
glare problem (n = 208) and problem in night vision (n = 389).
Mean visual acuity was 0.08 (6/72) in Snellen notation that ranged from
(0.004–0.33) 6/1500 to 6/18. The mean visual acuity with refractive
correction was 0.14 (6/42). The improvement of visual acuity from
baseline with refractive correction was statistically significant (p<0.05,
paired t test). The visual acuity with telescopes (n=303) was 0.43 (6/14).
When the patients whose residual vision was better than 0.05 (3/60)
were only taken into account, the mean presenting visual acuity was
0.13 (6/45) which improved to 6/30 with refractive correction. Mean
visual acuity with telescopes in this group (n=159) was 0.48 (6/12.5).
The improvement of visual acuity with both refractive correction and
telescopes were statistically significant p<0.05,pairedt test)
The mean presenting near visual acuity was 2.12± 1.49 M units which
improved to 1.63± 1.2 M units with different magnifiers. Similarly when
only the patients whose residual vision was better than 0.05 (3/60) in
the better eye were taken into account, the mean near visual acuity was
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Table 2. Table showing the prescribed devices for near.
Magnifiers
Spectacle magnifier
Hand Held Magnifier
Stand magnifier
Bar magnifier
Tele-microscopes
CCTV
Number of patients
Percentage
246
29
76
7
1
4
68.52%
8.07%
21.16%
1.94%
0.27%
1.11%
1.77± 1.22 M unit which improved to 1.29± 0.77 M units with low
vision devices. The improvement of near visual acuity with magnifiers
was statistically significant (p< 0.05,pairedt test) and improvement was
even more when the low vision persons had residual vision better than
0.05 (3/60).
There were 1107 (71.55%) patients who improved significantly with
refractive correction alone and were prescribed glasses. Eighty-eight
(5.68%) were prescribed telescopes. For near, only 359 (23.2%) patients
were prescribed magnifiers. Spectacle magnifiers was the most frequently
prescribed device for near.
DISCUSSION
Community based rehabilitation (CBR) is a home and community based
program for the blind people of the community, successfully running in
14 districts of Nepal. The main function of CBR is to identify the
incurably blind people and initiate suitable programs, such as early
intervention, education, orientation, mobility and vocational trainings.
Teachers in the developing country are best suited to provide health
education to the community. In our study, only 134 (8.66%) subjects
were referred by school teachers, 42 (2.71%) were referred by
Community based rehabilitation to the low vision clinics. This highlights
the need of active participation of teachers and rehabilitation workers
in this sector. The CBR program is successfully running in the Jhapa
District where Mechi Eye Hospital is situated but not in Siraha, where
Sagarmatha Choudhary Eye Hospital, Lahan is situated and this might
be the cause for the fewer number of patient referrals from CBR seen in
this study. The remaining patients were referred from the eye care
professionals that included ophthalmologists, optometrists and
ophthalmic assistants. Nepal is a country where the majority of people
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T H E B R I T I S H J O U R NA L O F V I S U A L I M PA I R M E N T 2 9 ( 3 )
live in rural communities and they have traditional beliefs in faith
healers. There may be advantages in training these faith healers to
identify the cases of possible visual impairment and encourage them to
visit the low vision clinics.
In this study, male to female ratio was 2.80. The male preponderance
was also seen in the study done by Mohidin and Yusoff (1998) where
the ratio was 2.21. It indicates that low vision was more prevalent in
males in Nepal, although it might also be linked to males having more
access to hospital care. In Nepal, gender-based discrimination is
widespread and extends to ownership of productive assets (such as
cattle), access to resources like land and other properties, access to
health and educational opportunities, work burden, access to public
decision-making positions, mobility, and overall cultural status. As a
result the structured dependence of women on men is high. Despite
progressive policy reforms, human development indicators of Nepali
women and girls, especially from marginalized castes and ethnicities,
living in remote areas, remain low (UNFPA Nepal, 2011). This suggests
that Nepal may benefit from a low vision screening camp in the
community which could give health education along with screening
services which particularly emphasizes the needs of female patients.
The mean age of presentation was 31.04±20.63 years ranging from
3–87 years. There were 501 (32.38%) patients in 0–15 year age group,
868 (56.10%) of patients were in >15–60 years age group and 178
(11.52%) in the >60 years age group. The majority of the patients were
from younger age groups which was similar to the result shown by
Mohidin and Yusoff (1998). In their study, 73.8 percent of patients were
younger than 60 years. The fewer number of patients in the age group
>60 years might be due to lower life expectancy (65.81 years) of the
country (Nepal life expectancy at birth, 2010). In our study, 1379
(89.1%) patients were from rural areas and only 168 (10.9%) patients
were from urban areas. In Nepal, more than 80 percent of the population
live in villages and the hospitals where the study was conducted are in
close proximity to villages.
Refractive error and amblyopia (24%) and retinitis pigmentosa (22.4%)
were the most common causes of low vision in the study population.
Other causes included globe anomalies (9.57%), optic atrophy (8.9%),
congenital cataract (8.7%), heredo macular degeneration (7.69%), age
related macular degeneration (5.7%), nystagmus due to unknown
causes (4.1%), glaucoma (2.2%), albinism (1.1%) and others (1.2%).
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Mohidin and Yusoff found structural and functional defect of globe
(13%), retinitis pigmentosa (13%) and heredo macular dystrophy (10%)
as causes of low vision in their study (Mohidin and Yusoff, 1998). An
exceptionally high percentage of refractive error and amblyopia reflects
the burden of refractive error in this part of the world. It might be due
to nuclear sclerosis which was not operated upon due to lack of
facilities and had visual acuity better than 6/36 with spectacles. In this
region, surgery is usually indicated only when the improvement with
spectacles was not better than 6/60.
Causes of low vision were analysed separately in different age groups.
The most common causes of low vision were refractive error and
amblyopia (30.33%), retinitis pigmentosa (13.97%) and globe anomalies
(15.1%) and congenital cataract (11.8%) in the 0–15 years age group.
In a study done by Elfadul Mohamed and Binnawi, retinitis pigmentosa
was the commonest (16.7 %) followed by congenital cataract (14.2 %)
(Elfadul Mohamed and Binnawi, 2009). In a study by Bamashmus and
Al-Akily, the commonest causes of bilateral blindness were cataract
(20.0%), glaucoma (17.8%), retinal disorders (13.3%) and corneal nontraumatic opacities (13.3%) (Bamashmus and Al-Akily, 2010). Again the
high percentage of refractive error and amblyopia as a cause of low
vision seeks attention of the eye care planners to initiate much more
pre-school and school screening programs to reduce the visual
impairment in the paediatric age group.
Similarly, retinitis pigmentosa (29.03%), refractive error (23.61%) and
heredo macular degenerations (10.13%) were the most common causes
of low vision in >15–60 years age group. Age related macular
degeneration (36.5%), retinitis pigmentosa (14.04%) and optic atrophy
(13.48%) were the most common causes of low vision in the age group
>60 years. Similar results were shown by Mohidin and Yusoff (1998).
The fewer number of age related macular degeneration patients in the
study population was probably due to relatively fewer number of
patients in the elderly age group.
Out of 1547 low vision patients, 819 (52.9%) were bilaterally blind and
only 725 (47.1%) had residual vision better then 3/60 in the better eye
in contrast to the study by Elfadul Mohamed and Binnawi (2009) where
a higher number of bilateral blind persons reflects the poor health
awareness and accessibility to health services in this part of the country.
A large number of patients (39.10%) had avoidable causes for visual
impairment. This reflects the lack of awareness and inaccessibility of
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T H E B R I T I S H J O U R NA L O F V I S U A L I M PA I R M E N T 2 9 ( 3 )
primary eye care to the patients in this area. This may benefit from both
governmental and nongovernmental organization attention.
The improvement of visual acuity for near and distance was significant
after provision of low vision devices. Even refractive correction alone
had resulted in significant improvement in visual acuity while telescopes
improved visual acuity to make their visual status near to normal. The
improvement of visual acuity was more when only the patients were
taken into account whose vision was better than 3/60 at presentation.
Hence the low vision service has better impact when the patient has
better residual vision. This result emphasizes the strengthening of the
primary eye care program so that cases of low vision can be detected
at an earlier stage where the impact of the service is greater. There were
1107 (71.55%) patients who improved significantly with refractive
correction alone and were prescribed spectacles. Telescopes were
prescribed to 88 (5.68%) patients.
Mohidin and Yusoff have shown that 60 percent of low vision clients
were prescribed at least one low vision device (Mohidin and Yusoff,
1998). For near, only 359 (23.2%) patients were prescribed magnifiers.
More than 90 percent of the optical devices like spectacles, hand held
magnifiers, spectacle magnifiers, were simple to use and are easily
available in the eye hospitals.
CONCLUSION
The low vision service through the low vision clinics in the eastern
region of Nepal is satisfactory in terms of the number of patients
attending the clinics. A good number of patients visit low vision clinics.
But the patients presented to the clinics usually are bilaterally blind. So
there needs to be a screening program for low vision patients in the
community which can identify patients earlier. The services provided at
the low vision clinics in this part of the country are satisfactory, as after
the provision of the devices, the visual functions have improved
significantly. The majority of devices are available in the local low vision
clinics at the hospital. The National Low Vision Program is supporting
the patients by providing the low vision devices at a 10 percent subsidy.
Only providing low vision services to the people with low vision does
not solve the problem. There should be a proper monitoring on the use
of devices and the impact they have upon patients after the provision of
low vision services. Nevertheless, such follow-up work is expensive and
currently limited. Close work with school teachers and community
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blind rehabilitators may offer more affordable ways of undertaking this
evaluation. Greater communication between low vision services and
other community-based services therefore seems a priority.
The higher incidence of avoidable blindness draws attention to the
need to strengthen primary eye care and emphasize early detection
and the necessary action. Uncorrected refractive error has been one
of the major causes of visual impairment. There should be improved
planning to reduce the burden of refractive error by health education,
school screening and community screening. Early diagnosis of the
refractive errors with easy availability of spectacles at affordable
prices appears to be the most effective method to address the problem
of low vision for many people. Other causes of visual impairment like
corneal opacities and glaucoma can also be reduced by proper
screening in eye camps. In conclusion, we would argue that in Nepal
(with its relatively low health awareness) this aspect of eye care
activity in low vision needs to be strengthened and prioritized by
policymakers.
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AJIT KUMAR THAKUR
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Email: ajitfriend2002@yahoo.com, ajitfirend2002@gmail.com
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