APRIL 2019

Levandi Mulya, MDSyumarti, MD

Community Ophthalmology

CONTENTS

4Global Burden Disease Regions

6Overall Trends and Pattern

The decline in age-standardized prevalence of visual impairment between 1990 and 2015

8Changes Over Time

the prevalence of visual impairment increases rapidly with age

9The Future

A vita l component of healthcoverage

11Universal Eye Health

To track global action progress

12Country Data

Our call for action to leaders, polcymakers and practitioners in all countries to implement the Gloibal Action Plan

13A Call For Action

1INTRODUCTION

2VISION ATLAS

9GLOBAL ACTION PLAN

The world is split, for administrative and data analysis purposes.

Nowadays trends of causes of visual impairment

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INTRODUCTION

sector to tackle what is largely an avoidableproblem.

The IAPB Vision Atlas brings togetherthe latest data and evidence related to avoidableblindness and sight loss; tells the story behind thenumbers; presents solutions, and good practice;highlights the opportunities to eliminate someblinding conditions; and warns of emergingthreats that, if ignored, could reverse theprogress that has been made in reducingprevalence over the past 25 years.

oday, the world is populated by hundreds ofmillions of people who are unnecessarily

blind or visually impaired from causes that aretreatable or preventable. Proven and highly cost-effective solutions exist but have not been takento scale. The Vision Atlas, launched by theInternational Agency for Prevention of Blindness(IAPB) is an excellent visualisation tool based onGlobal Vision Database data. The Vision Atlascreate a public conversation that helps persuadedecision-makers in government and the private

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he IAPB Vision Atlas isdesigned around two mainsets of data: the estimates of

the burden of blindness and visualimpairment made by the Vision LossExpert Group (VLEG) and national levelperformance against the key indicatorslaid out in the World Health Assemblyresolution 66.4 ‘Universal Eye Health: aGlobal Action Plan 2014 – 2019’ (theGAP). The Atlas will include two newmaps—the main causes of blindnessand visual impairment (by region) andthe main causes of near-vision loss (byregion, and only for 2015 withprojections for 2020) and can beviewed for all ages or for adults over50. The prevalence data will go back to1990 and will also include projections

to 2020. These numbers will be bycountry and can be accessed througha couple of web-based interactivemap. Introduced on World Sight Day2017, they have additional maps forthe 21 GBD Regions showing causesand the numbers affected by Near-Vision Loss. The GAP indicator data – alimited, initial survey of available data– gives you CSR/CSC data, humanresources and national planning data.Apart from this, the atlas will alsoinclude commentary on thesenumbers along with explanations andeasy-to-use tools for various eyeconditions. The website will befollowed by a published form of theIAPB Vision Atlas that will include allthe latest VLEG data covering the

period up to 2015.1

Together with a morecomprehensive breakdown of thecauses of visual impairment andprojections of prevalence to 2050,provides a rich mix of information andnew evidence. These data sets providea wealth of information relevant topolicy makers, health planners, NGOs,eye health professionals, patientgroups and advocates.1

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The IAPB Vision Atlas is a compilation of the very latest data and evidence relevant to all those

who believe that in the 21st Century no one should haveto live with avoidable blindness or sight loss

““Figure 1. Interactive vision atlas: MSVI data of all ages in 2015Source: IAPB Vision atlas1

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Given that so much of avoidablesight loss is a consequence of inequityand lack of access for the mostdisadvantaged members of our globalcommunity, The IAPB Vision Atlas is animportant resource for thoseresponsible for achieving UniversalHealth Coverage and theimplementation of the SustainableDevelopment Goals. The VLEG andGAP data are supplemented with anumber of articles speciallycommissioned for the IAPB VisionAtlas.1

These include a focus on theexciting potential toeliminate Trachoma and Onchocerciasis within the next decade, diseasesthat have ravaged communities forcenturies. Such optimism is temperedby articles on the global explosion inthe number of peoplewith myopia and diabetes thatthreaten to reverse the reduction invision loss prevalence we have seenover the past 25 years, together witha seemingly inexorable risein presbyopia.1,2

Other articles focus on the socio-economic impact of vision loss,the cost effectiveness of eye caresolutions and case studieson programme approachesand financing of eye health. The IAPBVision Atlas also identifies a wealth ofresources available to help combatavoidable visual impairment and, forthose less familiar with the sector,an introduction to the main eyeconditions.1,2

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Figure 2. Interactive vision atlas: Blindness data of all ages in 2015Source: IAPB Vision atlas1

Figure 3. Interactive vision atlas: causes of blindness in 2015Source: IAPB Vision atlas1

he group used the 21 regionsdemarcated by the GlobalBurden of Disease study to

disaggregate the global data andprepare regional estimates. These21 regions cluster countriesaccording to their physical locationbut also other factors, includingtheir socio-economic status. Eightynine percent of visually impairedpeople live in low- and middleincome countries. Three Asianregions are home to 62% of thepeople in the world with visualimpairment, even though they arehome to only 51% of the world’spopulation: South Asia (73 million),East Asia (59 million) and

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Figure 4. 21 GBD regions of vision atlasSource: IAPB Vision atlas1

South East Asia (24 million). At the otherend of the scale, the five high-incomeregions account for 14% of the world’spopulation but only 11% of people withvisual impairment.1,2,3

Comparing regions is not straightforwardif one just looks at the overall numbers orprevalence; this is due to the differences inthe age profile in each region; i.e. somepopulations may have a larger proportion ofolder people and fewer children comparedto others.

A technique called ‘age standardisation’makes it possible to compare populationswith different age profiles to each other andlook at changes over time. The age-standardised prevalence of visualimpairment across the 21 regions is shownin Figure 5. The prevalence in poorer regionsof the world is more than four times thatseen in the high-income regions. The grouphas also published a second paper that looksat the causes of visual impairment. Figure 6summarises the estimates of the causes ofblindness, moderate to severe visualimpairment, and for blindness and visualimpairment combined.1-3

Table 1. VLEG esrimates of the global number of people who are blind or MSVI, 1990-2050Source: Flaxman SR, et al2

Table 2. VLEG estimates for future population growth and ageingSource: Flaxman SR, et al2

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2015, there were an estimated 253 millionpeople with visual impairment worldwide. Of

these, 36 million were blind and a further 217 million hadmoderate to severe visual impairment (MSVI). Theprevalence of people that have distance visual impairmentis 3.44%, of whom 0.49% are blind and 2.95% have MSVI. Afurther 1.1 billion people are estimated to have functionalpresbyopia. As in earlier estimates, cataract continues to bethe leading causes of blindness, and uncorrected refractiveerror the leading cause of MSVI.1,2

The risk of most eye conditions increases with age;consequently, the prevalence of blindness and MSVI ismuch greater in older age groups. Of the 253 million visuallyimpaired people worldwide, 80% are aged 50 years orolder.1,2

A limitation of the causes estimates is the relatively highpercentage of “other” causes (25,5% for blindness; and13,2% for MSVI with an overall figure of 14,9% for visualimpairment). This is because a substantial number of thepopulation studies only report on the more prevalentcauses and do not identify or disaggregate the less-common causes such as macular degenerativecondition, retinopathies, optic neuropathies,and amblyopia.1-3

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6Figure 6. Causes of global blindness and MSVISource: IAPB Vision atlas1

Of the 253 million people in the world who arevisually impaired, 55% are women (139 million). Anumber of factors contribute to this genderimbalance, including the longer life expectancy ofwomen compared with that of men, whichmeans that there are more women in those agegroups associated with a higher risk of developinga sight-threatening eye condition. In addition,women are at greater risk of developing certaineye conditions. In some countries, women sufferdisadvantages in terms of access to eye healthservices. This problems is due to multiple socio-economic and cultural factors.1,3

Table 3. Age-standaridised prevalence for men and women in 2015 at the global levelSource: IAPB vision atlas1

Figure 7. Change in crude prevalence for females by ages (global) in 2015Source: IAPB Vision atlas1

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he group has produced global estimatesstretching back to 1990 and have also looked into

the future to produce estimates for 2020 to 2050; theresults are summarised in Table 1. At first glance, thegradual increase in the absolute number of people whoare blind or have MSVI from 1990 to 2015 may seemdisappointing. However, over this 25-year period, twovery important demographic changes have occurred,both of which would have been expected to give rise to amuch greater increase in the absolute number of visuallyimpaired people. First, the global population increasedby 38%: from 5.3 billion in 1990 to 7.3 billion in 2015.1,4

T Second, the world population aged and the totalpopulation over 50 years old almost doubled: from 878million in 1990 to 1,640 million in 2015. Allowing forthese two major changes, there is in fact an underlyingdecline in the global age-standardised prevalence ofblindness (all ages): it has reduced from 4.58% in 1990 to3.38% in 2015. A number of factors – including a declinein poverty levels, a reduction of the incidence of certainconditions or a later onset of these conditions, improvedpublic health measures and eye health servicedevelopment – have all contributed to this encouragingprogress.1,4

8Figure 8. The decline in age-standardized prevalence of visual impairmentSource: IAPB Vision atlas1

nited Nations data, whichsummarised in Table 2,informs us that the global

population was 7.3 billion in 2015.This is predicted to rise to 7.8billion by 2020 and to 9.7 billion by2050. The growing population isalso going to age at a much fasterrate than seen in previous years. In2015, there were 901 millionpeople over the age of 60 (12% ofthe global population). By 2050, thenumber of people over the age of60 is predicted to increase to 2.1billion (22% of the population).1,2,4

An even greater relativeincrease in the numbers of peopleaged ≥80 is expected;

the current estimate of 125 millionin 2015 is expected to increasemore than threefold by 2050: to434 million. As observed in Figure2, the prevalence of visualimpairment increases rapidly withage. By age 60, around 1 in 9people will be either blind or haveMSVI. By age 80, the ratio increasesconsiderably: around 1 in 3 peoplewill be either blind or haveMSVI.1,3,4

The combination of agrowing and an ageing populationwill result in a massive increase inthe number of people who areblind or have MSVI. Two otherfactors that also present a majorrisk for the future are the dramatic

increase currently being seen in allparts of the world in the number ofpeople with diabetes (which cancause diabetic retinopathy, apotentially blinding condition) andthose with high myopia. Overall,there may be some 703 millionpeople who are blind or have MSVIby the year 2050 (as shown inFigure 9). A massive investment ineye health services, along withprotection from out-of-pocketpayments for the poorest sectors ofsociety, is needed to ensureuniversal access to eye health for alland avert a future human andsocietal catastrophe.1,3,4

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Figure 9. The combination of a growing population and an ageing population threaten a massive increase in the numbers of people who are blind or are MSVISource: IAPB Vision atlas1

The GAP provides ‘indicators’ to measureprogress at the national level: the prevalenceand causes of visual impairment, thenumber of eye care personnel and CataractSurgical Rate (CSR) and Cataract SurgicalCoverage (CSC). The GAP recognizes thatprovision of effective and accessible eye careservices is the key to reducing visualimpairment including blindness, and thatembedding eye health in the broader health

system is necessary, and willreap efficiency and accessgains. The emphasis onUniversal Eye Health is alsoreflected in the principlescross-cutting the GAP whichinclude: ensuring universalaccess and equity; compliancewith human rightsmechanisms; accounting forhealth and social needs at allstages of life; and promotingempowerment of people withblindness and visualimpairment.1,5,6

the World Health Assembly in May2013, governments adopted

Resolution 66.4 Universal Eye Health: a GlobalAction Plan 2014-2019 making thecommitment to act to significantly reduceavoidable blindness around the world andand acknowledging theimportance of achievingUniversal Eye Health.1,2,5

Endorsed by all 194 WHOMember States, it is acommitment to improve eyehealth for everyone, includingaccess to rehabilitationservices for those with visualimpairment. This meansgovernments are central toensuring access to quality eyehealth services. The GlobalAction Plan (GAP) builds uponprevious VISION 2020 andWHO 2009 – 2013 ActionPlans. The GAP sets outobjectives and means toachieve significant reductionsin avoidable blindness andvisual impairment world-wideand the responsibilities of the differentstakeholders – governments, WHO andinternational partners. The objectives are onevidence, used to advocate for politicalcommitment and investment, developmentand strengthening of national plans advancinguniversal eye health, and strengthening multi-sector engagement and partnership. A majoradvance in the 2014-2019 GAP was theintroduction of a clear target – a 25%reduction in the number of people withavoidable blindness and visual impairmentby the year 2019, compared with the2010baseline.1,5

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The WHO defines universal health coverage (UHC) – and therefore Universal Eye Health – as

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a vital component of health coverage

ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health

services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship

when paying for these services

This means that all people should enjoy access to quality eye health, and out-of-pocket payments should not impede access or cause difficulties.

Universal Health Coverage is of great importanceas, in essence, it is grounded in the right to healthwhich includes ensuring access to services withoutdiscrimination and progressively realising qualityhealth services for all. UHC will require strengtheninghealth systems and providing access to services forall people particularly those unable to pay for orotherwise unable to access health care. If done rightUHC can be, as WHO Director General MargaretChan has called it, ‘a major equalizer’: “Universalhealth coverage is one of the most powerful socialequalizers among all policy options. It is the ultimateexpression of fairness.” This applies also to achievingUniversal Eye Health and, as such, there are anumber of elements that governments and otherstakeholders should account for. Eye health needs tobe integrated into strengthened health systems, withsufficient and well- distributed services andpersonnel.1,6

Services must be comprehensive; that iscovering the range of causes of vision impairmentfrom promotion, prevention to rehabilitation andcare

It will require elimination of barriers that can affectaccess for vulnerable sectors of the populationincluding women, people with disabilities, older people,indigenous peoples and people living in rural areas.

Finally, point-of-care payment should not preventaccess. Advancing towards Universal Eye Health willrequire maximising opportunities including the SDGUHC target, and advocating for incorporation of eyehealth such as surgeries, glasses for children and low-vision services within social insurance and otherschemes to progress UHC. This is especially importantas financing for health is expected to increasingly comefrom domestic sources. Cataract Surgical Coverage forexample, has been recognised within the WHO/WorldBank UHC monitoring report as an important indicatorfor older people’s access to health care, this cansupport arguments to include Cataract in essentialpackages. On inclusion of eye health in these schemesit will be crucial to monitor delivery and advocate toensure that policy translates into practice in a way thatprogresses towards universal eye health.1,6

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To track global action plan progress

WHA resolution identifies five keysindicators as well as 13 supplementaryindicators that should be measured tomonitor progress. IAPB has collectedinformation on the five key indicator plus fiveof the supplementary indicators from 197countries.1,7

We will find below an analysis of the datacollected. Though the amount of data wecollected surpassed our expectation for someof the indicators, it was difficult to get reliabledata from countries.

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economic hardship were identifiedas one major cause of not accessingeye care services. Financing forhealth systems in countries needsto ensure that early identificationand screening, eye care treatments,essential eye care drugs andassistive devices required areaffordable for all, especially forthose living in poverty and othermarginalised groups.

Ensure eye health is equitable andinclusive.A recent assessment of avoidableblindness and visual impairment inseven Latin American concludesthat ‘Blindness and moderate visualimpairment prevalence were fixedamong the most sociallydisadvantaged, and cataract surgicalcoverage and optimal outcomewere concentrated among thewealthiest’. In addition to buildappropriate financing mechanisms,it requires:1,6,7

• a proactive approach in eye health promotion at the community level as part of primary health care

• consistent follow up on community screenings

• sensitization and training of staff to reduce attitudinal, communication and institutional barriers-to-access for patients from socially excluded groups

Work together in eye healthThis call for increased resources andfocus on eye health comes at a timewhen many governments areresponding to the new andexpanded UN SustainableDevelopment Goal. It is vital that allstakeholders work together at thenational level, within a broadernational development plan.

outside the eye health sector addressesfour crucial elements:

Get eye health mainstreamedEye health affects a country’spopulation at all ages. Eye health islinked to other health issues and also tothe social determinants of health andeconomic poverty. Therefore, treatingeye diseases and managing vision loss atindividual and societal levels should beintegrated within general healthsystems. Eye health specialists shouldengage in all health systems’ buildingblocks, including financing schemes.Policy makers and sector strategistsmust include the promotion of goodeye health in their policy frameworks.

Make eye health affordableIn a systematic review of barriersto cataract surgery in Africa,poverty and

he Global Action Plan onUniversal Eye Health (GAP)

requests all stakeholders to join into realize its ambitious vision:a world in which nobody isneedlessly visually impaired. A Callfor Action to leaders, policy makersand practitioners from inside and

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1. International Agency for the Prevention of Blindness. Vision Atlas[document on the internet]. London: IAPB Vision Atlas; 2019.Available at http://www.atlas.iapb.org/

2. Flaxman SR, Bourne RRA, Resnikoff S, Ackland P, Braithwaite T,Cicinelli MV, et al. Global causes of blindness and distance visionimpairment 1990-2020: a systemic review and meta-analysis.Lancet Glob Health 2017; 5: e1221-34.

3. Bourne RRA, Stevens GA, White RA, Smith JL, Flaxman SR, PriceH, et al. Causes of vision loss worldwide, 1990-2010: a systematicanalysis. Lancet Glob Health 2013; 1: e339-49.

4. Bourne RRA, Flaxman SR, Braithwaite T, Cicinelli MV, Das A, JonasJB. Magnitude, temporal trends, and projections of the globalprevalence of blindness and distance and near visionimpairment: a systemic review and meta-analysis. Lancet GlobHelath 2017; 5: e888-97

5. Nemeth J, Toth G, Resnikoff S, Tjeerd de Faber J. Preventingblindness and visual impairment in Europe: what do we have todo? European Journal of Ophthalmology 2018; 00 (0): 1-4.

6. Silva JC, Mujica OJ, Vega E, Barcelo A, Lansingh VC, McLeod J, etal. A comparative assessment of avoidable blindness and visualimpairment in seven Latin American countries: prevalence,coverage, and inequality. Rev Panam Salud Publica 2015; 37(1):13-20.

7. Aboobaker S, Courtright P. Barriers to cataract surgery in Africa: asystemic review. Middle East African Journal of Ophthalmology2016; 23(1): 145-149.

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