Sustainable Global Vision Care

UN adds eye care to development goals; remote training helps meet need. Howard Larkin reports

International policy development and remote training technology are converging to help eliminate preventable blindness.

For the first time, the United Nations General Assembly has affirmed the need for vision care to eradicate poverty and promote worldwide development. Sponsored by Bangladesh, Antigua, and Ireland, and co-sponsored by more than 100 countries, the “Vision for Everyone” resolution was adopted in July by unanimous consent of the organization’s 193 members.

The resolution calls for adding eye health targets to the Sustainable Development Goals (SDGs), the UN’s ambitious roadmap for transitioning to greener, more inclusive economies across the globe by 2030. The SDGs are 17 general goals ranging from eliminating poverty and hunger to promoting gender equality and quality education to developing economies and infrastructure in sustainable ways. The new eye care resolution mostly falls under the universal health coverage provisions of SDG 3, ensuring good health and well-being for all while also contributing to all the others.

Explicitly adding eye care not only raises its visibility as a global good but encourages support from the many governments and private donors around the world that embrace SDGs in their development and funding strategies, said ESCRS President Rudy MMA Nuijts MD, PhD. ESCRS plans to play a role.

“The resolution asks for international financial institutions and donors to provide targeted finances, especially to support developing countries, in tackling preventable sight loss. This is a significant milestone, and the ESCRS, not least through its Charitable Committee, is ready to support the aim of making eye care services more widely available [and] an integral part of universal healthcare,” Dr Nuijts said.

PRESSING NEED Adding two eye health indicators—rate of effective cataract surgical coverage and rate of effective refractive error coverage—to outcomes reported for SDG 3 is especially important, said Matthew J Burton PhD, FRCOphth, director of the International Centre for Eye Health (ICEH) at the London School of Hygiene & Tropical Medicine, London, UK. “It means that countries will have to measure and report what they are doing in these areas.”

This creates an incentive to allocate state resources to eye care, Prof Burton added, who is also co-chair of the Lancet Global Health Commission on Global Eye Care and lead author of its February 2021 report.i

Photo credit: UN Photo/Olivier Chassot | A Nepalese doctor with the African Union-United Nations Hybrid Operation in Darfur (UNAMID) checks a young boy’s eyes, as part of a seven-day, free medical campaign provided by UNAMID to the population of Shangil Tobaya, North Darfur. More than 2,000 individuals, including women and children, received medical treatment from UNAMID’s Nepalese Special Forces, Mongolian Level II hospital personnel and Rwandan protection force and medical personnel.

The two eye health indicators are also important because they address about 80% of avoidable blindness and moderate to severe visual impairment (MSVI), Prof Burton said. According to the Commission report, about 157 million people suffer MSVI due to uncorrected refractive error and about 83 million from cataract. There are a further 17.1 million who are blind from cataract and 3.7 blind from uncorrected refractive error.

BUILDING CAPACITY About 90% of people with vision impairment live in low- to middle-income countries—with many in remote rural areas, Prof Burton said. More research to find where the need is greatest and how to address it in rural areas is critical to development, he added. These solutions need to integrate eye care with general primary care in national health plans and delivery systems.

“Eye care has been on the fringe of healthcare, often looked after by NGOs rather than by national health systems. It has tended to be neglected.”

Building local capacity and ensuring access for vulnerable populations are major goals for Orbis programmes, according to Doris Macharia MD, senior vice president, Global Programs, Orbis International, London, UK.

For example, working with the Rohingya population and local people in Bangladesh, “Our focus is on strengthening the integration of eye care services into the primary healthcare system, improving the capacity of partner hospitals, deployment of mHealth platforms for diagnosis and data management, and establishing emergency referral systems.”

Similarly, Orbis has integrated a trachoma elimination programme with the national health system in Ethiopia and integrated eye care services into existing Universal Child Immunization programmes in Zambia. Other programmes are underway in Africa, Latin America, Asia, and the Caribbean.

With low- and middle-income countries still reeling from COVID-19, and its damage to eye care and health systems generally, Dr Macharia also welcomes the UN action.

“Adding eye care to the SDG framework is a major step forward and affirms the importance of including eye health as part of Universal Health Coverage.”

SIMULATION TRAINING New training practices, including extensive use of simulations and remote learning, are essential to building the necessary capacity to surgically treat cataract, glaucoma, and other causes of blindness in LMICs, according to presenters at the Orbis Symposium at the 39th Congress of the ESCRS in Amsterdam.

While factors such as cost and backlogs from the COVID-19 pandemic are significant, patient safety is the most important reason to train using simulations, said John Ferris MB, ChB, FRCOphth, head of the School of Ophthalmology–Severn Deanery, and consultant surgeon at Gloucestershire Eye Unit, Cheltenham, UK.

“In the twenty-first century, it is frankly unacceptable for any surgeon anywhere in the world to be undertaking a surgical manoeuvre for the first time on an actual patient.”

The goal of the simulation is for trainees to develop competence in basic manoeuvres such as instrument handling and suturing skills, Dr Ferris said. Course material is available for many ocular surgical procedures, including trabeculectomy, small-incision manual cataract surgery, and strabismus, through Orbis.ii

The process starts with pre-course learning, watching videos, and instructional courses, which can be done online. Then trainees move to develop basic skills, such as cutting a trabecular flap on apples or simulating releasable sutures on plastic foam before moving to model eye simulations. Sustained, deliberate practice on these inexpensive materials between lessons is critical, Dr Ferris added.

Equally critical is evaluating skills using the “ophthalmic simulates surgical competency assessment rubric” (OSSCARS) to help trainees advance from novice to competent in each surgical step before going on to treating live patients. Recording simulations and having trainees score their own performance is very helpful, Dr Ferris said.

“This scoring tool can easily differentiate between novice and expert surgeons.”

Digital dry labs enable one instructor to monitor as many as eight trainees practicing at once, Dr Ferris said. Such labs can be conducted remotely, allowing one expert to help trainees in many parts of the world. With one camera showing the surgical field and another showing the trainees’ hands, Dr Ferris can provide real-time coaching on hand positioning and suturing techniques remotely.

Similar remote sessions have been conducted for everything from capsulorhexis and small-incision cataract surgery to strabismus muscle repair, and many can be seen online.iii It can even be conducted with a cell phone camera and a homemade model eye, Dr Ferris said.

Studies show simulation improves patient safety and outcomes, he added. One randomised trial compared 25 trainees who received simulation training early in their study with 25 who received conventional training with simulation added after one year. The early simulation group improved their skills three-fold over the conventional group in the first three months of training and had higher confidence scores. In their first year operating on patients, the early simulation group had 2.5 times more cataract cases, with complication rates 72% lower than the conventional group and a posterior capsule tear rate of 7.4% versus 26.2% in the control group.iv Results were similar in a study of glaucoma surgical skills.v

Remote mentoring can help democratise surgical training, Dr Ferris said. “It doesn’t have to be high tech nor expensive. Trainees can teach themselves the basics of many surgical techniques.”

Photo credit: UN Photo/Stuart Price | An elderly man undergoes an eye examination from a Ugandan ophthalmic clinical officer, serving with the African Union Mission in Somalia (AMISOM). Free medical services are being provided by AMISOM personnel at the Qatar Camp for Internally Displaced Persons (IDPs) in Mogadishu as part of a week-long programme called Tarehe Sita — Kiswahili for “6 February” — the date which commemorates the establishment of the Ugandan People’s Defence Force (UPDF).

Rudy Nuijts rudy.nuijts@mumc.nl

Matthew Burton matthew.burton@lshtm. ac.uk

Doris Macharia via Anna Kharbanda AKharbanda@orbis.org.uk

John Ferris john.ferris2@nhs.net

i https://globaleyehealthcommission.org/ ii Cybersight.org iii gallery.simulatedocularsurgery.com iv Dean WH et al. JAMA Ophthalmol 2021; 139(1) 9–15. v Dean WH et al. BJO published online 25 January 2021.