Eye Care in Developing Nations 4th Edition
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For Martha, who understands, and for Eric, Mark, and Angela, who share the journey.
Love is the greatest healer to be found
Willie Nelson, in his song Angel Flying Too Close to the Ground
Photographic credits:
Aravind Hospitals: chapt. 1 facing, 7, 49–54, 56–58, 60, 61, 64, 65, chapt. 6 facing
Harjinder Chana: 108
International Campaign to Ban Landmines: 94
International Centre for Eye Health: chapt. 13 facing, Murray McGavin, 155/Aravind
International Eye Foundation: front cover top insets, chapt. 2 facing, 8–10, 11
Merck Pharmaceuticals: 115
Larry Schwab: front cover, Malawi children, 1–6, 13–22, chapt. 4 facing p, 23–35, chapt. 5 facing,
40–44, 46, 47, 77–80, 80, 83, 84, 86, 89, 92, 93, 95, 96, 100–107, 109–112, chapt. 10 facing, 121, 122,
chapt.11 facing, 125–127, 129, 130, 132–134, 144, 146, 147, 149 chapt. 14 half tone, part 3 half tone
Ivan Schwab: 97, 99, 123, 4, 128, 136–143, 145, 150, 153
Martha Schwab (original drawings, color enhanced and modified by Kate Nardoni): 12, 22, 38, 55,
59, 62, 63, 68, 70, 72, 74–76, 81, 83, 85, 87, 98, 151, 152, 154, 157–169, 172
Marty Spencer: 48, 148
Jim Standefer: cover, lower right inset, 36, 66, 67, 69, 71, 170, 171
Jeff Watson: 117, 119
World Health Organization: 81, 82, 88, 90, 91, 113, 114, 118, 120, 131
Copyright © 2007 Manson Publishing Ltd
UK edition: ISBN 978-1-84076-084-2
Indian sub-continent edition: ISBN 978-1-84076-103-0
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or
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Commissioning editor: Jill Northcott
Project manager and book design: Ayala Kingsley
Copy editor: Alan Bellinger
Illustration: Cactus Design and Illustration
Colour reproduction: Tenon & Polert Colour Scanning Ltd, Hong Kong
Printed by: New Era Printing Co Ltd, Hong Kong
Contents
Foreword 10 2 Sustainable eye programs 47
About this book 11 General considerations 47
Preface 12 Sustainability defined 48
Acknowledgments 14 The IEF’s approach 49
Glossary 15 IEF SightReach® management program
49
PART 1 Summary 52
Public health ophthalmology
3 Appropriate technology 53
1 Public health, preventive care, Equipment for ocular examination 54
and eye care delivery 35 Visual acuity charts 54
Public health ophthalmology 36 Pinhole 55
Preventive eye care 36 Eyelid retractor 55
Trachoma 36 Viewing aids 55
Ophthalmia neonatorum 36 Instruments and techniques for ocular
surgery 56
Conjunctivitis and corneal ulcer 37
Portable operating light 56
Eye injuries 37
Locally manufactured cryoextractor 57
Glaucoma 38
Intracapsular cataract extraction without a
Amblyopia 38
cryoprobe 58
Nutritional blindness 38
Surgical headrest 58
Onchocerciasis 39
Eyelid plate 59
Corticosteroid use 39
Surgical blades 59
Primary health care and primary
Surgical cautery 59
eye care 40
Sterilization 60
Organization and delivery of eye care 42
Expendable ophthalmic supplies 61
Intraocular surgery by non-ophthalmologists
44 Protective eye shield 61
Eye surveys 45 Locally produced ophthalmic medications
and spectacles 61
Epidemiological terminology 45
Eye pads, surgical sponges, and suture 62
Donated supplies 62
Contents
PART 2 6 Glaucoma 99
Introduction, background, and
Blinding disorders and epidemiology 99
eye care Classification 101
Primary open-angle glaucoma 101
4 Childhood blindness 65
Angle-closure glaucoma 101
Blinding malnutrition 65
Secondary glaucoma 102
General considerations 65
Childhood glaucoma 102
Diagnosis and management History 67
Examination, history-taking, and
Signs of vitamin A deficiency 67 diagnosis 103
Treatment and prevention 68 Primary open- angle glaucoma 103
Corneal scarring from vitamin A Chronic angle-closure glaucoma 105
deficiency 70
Acute angle-closure glaucoma 106
Measles and childhood blindness 70
Secondary glaucoma 106
Prevention of blindness from measles 71
Childhood glaucoma 107
Congenital cataract 72
The optic nerve in glaucoma 107
Retinoblastoma 72 Visual fields in glaucoma 108
Retinopathy of prematurity 72 Medical management 109
Congenital glaucoma 73 Medications used to lower intraocular
Conjunctivitis in newborns 73 pressure 109
HIV/AIDS and malaria 73 Primary acut angle-closure glaucoma 111
Screening of children 73 Pain in end-stage glaucoma 112
Surgical management 112
5 Cataract 75 Filtration surgery 112
Epidemiology 75 Iridectomy and iridotomy in acute primary
angle-closure glaucoma 113
Defnition and etiology 76
Special considerations 114
Anatomy of the crystalline lens 77
Management of secondary glaucoma 114
Classification 77
Intraocular inflammation and
Prevention 79 secondary glaucoma 114
Surgical management 79 Neovascular glaucoma 115
General considerations 80 Cataract and glaucoma 115
Indications for cataract surgery 80 Prevention of blindness from glaucoma
General surgical technique 81 115
Preoperative considerations 82 Early diagnosis 115
Intraoperative technique 84 Early surgery 115
Postoperative considerations 93
Surgical equipment 97
Contents
7 Trachoma 117 9 Onchocerciasis 139
Epidemiology 117 Natural history 139
Clinical diagnosis 119 Pathways to blindness from
Grading system 122 onchocerciasis 140
Medical management of trachoma 124 Diagnosis 140
Topical antibiotics 124 Management 141
Systemic antibiotics 124 Medical management 141
Surgical management of entropion Management of ocular onchocerciasis 142
and trichiasis 124 Surgical management 142
Epilation 124 Elimination of onchocerciasis
Electrolysis 125 blindness 143
Cryoablation 125
Trichiasis surgery 125
10 Leprosy 145
Public health and trachoma 125
Epidemiology 146
SAFE strategy 126
Pathways to blindness from leprosy 146
GET 2020 126
Corneal opacity 146
Uveitis 147
8 Ocular trauma 127
Cataract 147
General considerations 127
Diagnosis 147
Patching 128
Treatment 148
Injuries to the eyelids 128
Medical 148
Contusion 128
Surgical 149
Laceration 128
Leprosy and public health 149
Lacrimal drainage system 129
Social aspects of leprosy 149
Burns 129
Orbital injuries 130
Ocular surface injuries 130
Corneal foreign body 131
Corneal abrasion 132
Corneal chemical injuries 132
Contusion to the eyeball 133
Hyphema 133
Iridoplegia 133
Lens dislocation 133
Ocular fundus injuries 134
Penetrating injuries to the eyeball 134
Intraocular foreign bodies 135
Harmful eye practices 136
Antipersonnel landmines 137
Contents
11 External disease 151 Evaluation and management of uveitis
174
Conjunctivitis 151
Evaluation 174
Non-purulent conjunctivitis 151
Management 175
Purulent (bacterial) conjunctivitis 154
Corneal ulcer 156
13 Refractive errors 177
Bacterial corneal ulcer 157
Fungal corneal ulcer 159 Refractive error 178
Keratitis 160 Myopia 178
Herpes simplex keratitis 161 Hyperopia 179
Other external diseases 162 Presbyopia 179
Astigmatism 179
Pterygium 162
Aphakia 179
Pinguecula 162
Pseudophakia 179
Squamous cell carcinoma and basal cell
carcinoma 163 Optics 180
Keloid 163 Equipment and instruments 180
Conjunctival pigmentation 163 Methods of measuring refractive error
Phlyctenule 163 181
Scleritis 164 Objective refraction with instruments 181
Blepharitis 164 Subjective refraction 183
Hordeolum 164 Asthenopia 183
Chalazion 164 Special considerations 184
Eyelid infection 165
Lacrimal disease 165 14 Low vision 185
Anthrax 166 Definitions 186
Causes of low vision 186
12 Other blinding disorders 167 Cataract 186
Diseases of the ocular fundus 167 Refractive error 186
Diabetic retinopathy 168 Corneal scarring 186
Macular degeneration 169 Macular degeneration 186
Retinal detachment 169 Glaucoma 187
Retinal degeneration 170 Ocular trauma 187
The retina in malaria 170 Onchocerciasis 187
Optic atrophy 170 Diabetic retinopathy 187
Strabismus (squint) 170 Congenital causes 187
Primary strabismus 171 Retinopathy of prematurity 187
Secondary strabismus 172 Professional, patient, and public
Uveitis associated with systemic awareness 187
diseases 172 Low-vision care 188
Tuberculosis 173 Identification and screening 188
Leprosy 173 Appropriate lighting and glare reduction 189
Syphilis 173 Optical aids: low-vision devices 190
Acquired immunodeficiency syndrome 174
Contents
PART 3 PART 4
Ophthalmology backgrounder Appendices
15 Anatomy and physiology 193 Appendix A Diagnosis of the red eye 212
Anatomy of the human eye and adnexa Appendix B Ocular medications 214
193 Appendix C Surgical guidelines for
General external anatomy and landmarks ophthalmic medical auxiliaries 217
193 Appendix D Basic equipment 218
External anatomy of the eyeball 194 Appendix E Equipment suppliers 220
Internal anatomy of the eyeball 195 Appendix F World Health Organization
Optic nerve and visual system 196 classification of visual impairment and
blindness 223
Eyelids 197
Appendix G Resource organizations 224
Lacrimal system 198
Appendix H Address book 247
Extraocular muscles 198
Appendix I References and Resources 254
Bony orbit 198
Physiology of the human eye 199
Index 257
General considerations 199
Aqueous fluid 200
16 The eye examination 201
General considerations 201
The ocular history 201
The ocular examination 202
Visual acuity 202
External ocular examination 204
Internal ocular examination 205
Tonometry 207
Examination of children 209
10
Foreword
T he prevention of blindness is known to be one of the most cost-effective
health interventions that can be undertaken. It should start at the individual,
family, and community levels. Primary eye care, as part of primary health care,
has thus been strongly advocated by the World Health Organization’s Program
for the Prevention of Blindness and Deafness in its long-standing partnership
with the International Eye Foundation and other non-governmental
organizations. To be meaningful, primary eye care must respond to local needs
and resources and must use opportunities for community support. This implies
priority for basic eye care, often in a difficult setting of resource constraints in
developing countries.
This book responds particularly well to the need for practical, innovative, and
affordable solutions to bring eye care to those populations most in need in the
developing world. The most common ocular disorders and their management
are described, including public health perspectives and appropriate guidelines.
I t is a pleasure and encouragement to note the continuing great success and
demand for the practical guidance to eye care given in this book. The time has
now come to provide the fourth edition, which includes a number of useful
updates.
The book contributes greatly to increasing the access to basic eye care
services in developing countries. Such services, along with appropriate public
health interventions, constitute the key to eliminating unnecessary visual loss in
future generations. The existence of effective public/private partnerships for the
prevention of blinding diseases, along with the rapid progress of ‘Vision 2020:
the Right to Sight’ global movement should make it possible to achieve that goal.
Bjorn Thylefors M.D., Ph.D., FRCOpht
Director, Mectizan Donation Program, Decatur, Georgia
11
About this book
T he text of this book has been written for mid-level eye health care workers.
For some people who will use it in the classroom and as a reference, this
book may be elementary; for others, it may be too complex. The aim is to present
the major causes of blindness and visual impairment in a concise and accessible
format. Ophthalmologists have found it to be useful as a resource guide.
Eye Care in Developing Nations is divided into three sections: Part 1, Public
health ophthalmology; Part 2, Blinding disorders and eye care; and Part 3,
Ophthalmology Backgrounder. Part 1 introduces concepts in public health
ophthalmology, an area that deserves more emphasis in the realm of blindness
prevention. Part 3, a basic primer in anatomy, physiology, and the ocular
examination, is primarily intended for non-physician eye-care workers in
developing nations. People who seek more complete information on ocular
anatomy and physiology should consult a standard ophthalmology textbook.
Ophthalmologists will likely find Part 2, the clinically oriented section, the
most useful in their practical efforts to prevent blindness and restore sight,
especially for those who are unfamiliar with ‘tropical’ ophthalmic conditions.
The glossary, which for easy reference now comes before the first chapter, has
been expanded from the third edition, as have the appendices. Key resource
organizations, both local and international, are described in Appendix G, and an
address list of these and others is listed in Appendix H.
Clinical points of special importance appear in boldface italics. Measurements
are listed in metric units. American units may be given for convenience in
parentheses subsequently; for example, a normal visual acuity would be given as
6/6 (20/20), that is, meters first, feet second.
Algorithms and treatment schedules follow World Health Organization
guidelines. Vision 2020 recommendations are included in the text. International
Agency for the Prevention of Blindness and International Council of Ophthalm-
ology information is also included in the International Agencies appendix.
Suggestions on how to improve future editions of this title would be
appreciated. You may reach the author through www.iefusa.org.
12
Preface
People do not go blind by the millions.
They go blind one by one, each in an individual and tragic way.
Sir John Wilson
’tis the gift to be simple
’tis the gift to be free
’tis the gift to come down where we ought to be
Shaker tune Simple Gifts, Joseph Brackett, Jr.
M illions of blind people live in our world. They do not go blind by the
millions, as the visionary Sir John Wilson, blind himself, once said.
If you have ever known a blind person, then you are likely aware of the
enormous physical, social, psychological, and economic toll that blindness
inflicts. But millions? Is it really possible to comprehend the magnitude of this
silent catastrophe?
The numbers are staggering: 37 million people blind and another 124 million
with low vision. A total of 161 million are visually impaired. One person goes
blind every five seconds, on average, and one child goes blind every minute.
At least 75% of all blindness is either reversible, in the case of cataract, or
preventable, as with trachoma and external eye infections, for example.
Ninety percent of all new blindness occurs in the developing world. Most of
those people are impoverished and have limited access to eye care. Most are
adults, but millions are children. Who among us can condone the tragedy of
childhood blindness that could have been prevented?
13
Should the international health care community, public health specialists,
administrators, political leaders, and concerned citizens forge a social contract
with those who are blind and people who are at high risk of blindness? I believe
they should. Many of us already have, as evidenced by the non-governmental
organizations and international agencies described in the resource appendices
of this edition. I believe it is an ethical and moral imperative that everything that
can be done to prevent blindness and restore sight should be done.
The intent of this book is simple and clear. Eye Care in Developing Nations
was first published in 1987 for medical assistants, clinical officers, and nurses
training and working in eye care in Africa. Two subsequent English editions
followed in 1990 and 1999. The title has been translated into Chinese, French,
Tibetan, and Vietnamese editions.
This fourth edition has been expanded and updated. New text, treatment
algorithms, and diagnostic criteria have been added. This is the first edition in
which color plates have been published. The varied photographs in this edition
depict both common and rare ocular conditions. Suggestions of colleagues and
co-workers have been taken into consideration in revising and expanding the
text and illustrations.
Somewhere today on the Gangetic Plain of northern India and southern
Nepal, a child, blind from corneal scarring secondary to vitamin A deficiency and
measles, will perish from starvation. A teenager in Indochina will detonate a
landmine with her innocent footfall while walking to school, taking her legs and
her eyesight. An African elder, his hair white with the dignity of age and his pupils
white with mature cataracts, will die, his sight-restoring surgery never
performed because he did not have access to eye care. An indigenous Latin
American, severely sub-sighted, will forego a trip to the eye specialist for
treatment of her glaucoma for lack of bus fare as she is slowly blinded by her
disease.
There is simultaneous tragedy and hope in these human snapshots. There is
tragedy because preventable blindness persists in a bountiful world, one of
unequal resource distribution. Hope, because in each instance, blindness could
have been prevented.
It is in the spirit of hope that this book can assist the international efforts and
local action in preventing blindness and restoring sight in disadvantaged
populations.
Larry Schwab
14
Acknowledgments
The author and publisher gratefully acknowledge the generous assistance, friendly
advice, and constructive criticism of these colleagues, friends, organizations, and family:
Sue Stevens of the International Centre for Eye Health was wonderfully supportive
and encouraging in the preparation of this edition. Her gift of time and energy was
enormously helpful.
Ayala Kingsley of Manson Publishing Ltd, was unstinting with her professional talent and
hard work. Her sense of purpose and good humor also contributed marvelously.
Aravind Hospitals, India, for collaboration and assistance in Chapter 2
John Barrows, International Eye Foundation (IEF), for co-authoring Chapter 2
Paul Courtright, KCCO, Tanzania, for suggestions and critique of Chapter 10
Jill Dorman, for indexing
John Forder, Manson Publishing, for proof-reading the final draft
Ken Gustavsen, Merck Pharmaceuticals, for generous support to make possible the
distribution of this title to eye health workers serving underserved people.
Tom Jackson, Manson Publishing, for final revisions and review
Susan Lewallen, KCCO, Tanzania, for suggestions and encouragement
Michael Manson, Manson Publishing, for his enthusiastic support of this title, blindness
prevention, and sight restoration
Kate Nardoni, for color artwork
Ramachandra Pararagasegaram, WHO, for suggestions and IAPB/WHO data
Raheem Rahmathullah, IEF, for co-authoring Chapter 2
Serge Resnikoff, WHO, for suggestions and WHO data
Martha Schwab, for the original line drawings
Victoria Sheffield, IEF, for co-authoring Chapter 2
Marty Spencer, Seva Foundation, for suggestions on Chapter 5
Jim Standefer, for valuable critique of Chapter 6
Bjorn Thylefors, Mectizan Donation Program, for critical review of Chapter 9
and Foreword
Jack Whitcher, Proctor Foundation, for critical reading and suggestions on Chapter 7
Credits:
Blindness and low vision data: World Health Organization, 2002
15
Glossary
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And to know the place for the first time.
T.S. Eliot, Four Quartets
It is a simple matter to make things complicated;
it is much more complicated to make matters simple.
Meyer’s Law
A afferent pupillary defect The ‘swinging
absolute glaucoma End-stage glaucoma. flashlight’ sign; a test with a focal light to
A condition in which there is no light determine if posterior segment or optic
perception (NLP) and usually pain, often nerve disease is present. In the affected
severe, from a glaucomatous process. eye, the pupil may be sluggish to constrict
to light and will not constrict further and
accommodation A change in the power of
may even dilate when the stimulus of light
the crystalline lens that allows the eye to
in the fellow eye is removed and ‘swung’ to
focus at near. Accommodation is accom-
the affected eye; an important clinical test.
plished by contraction of the ciliary muscle
with relaxation of the ciliary zonules and agonist A drug that stimulates physio-
thickening of the lens. The eye’s ability to logical activity.
accommodate decreases naturally with
AIDS Autoimune Deficiency Syndrome: a
age.
disease complex caused by a specific retro-
AC IOL Anterior chamber intraocular lens. virus (HIV) that attacks the immune
system, resulting in opportunistic infec-
acuity Visual acuity.
tions (including Herpes zoster and
acute In medical use, sudden or Kaposi’s sarcoma).
immediate.
akinesia Paralysis of movement of the eye
adenopathy Enlargement of lymph or eyelids by paralyzing the extraocular or
node(s); also called lymphadenopathy. orbicularis muscles using local anesthetic.
adnexa Ocular eyelids, lacrimal system, allopathy A system of health care practice
extraocular muscles, orbit, and other sur- that attempts to produce a condition
rounding structures of the eyeball. opposite to the disease state in an attempt
to cure the disease. Compare homeopathy.
16 Glossary
amblyopia Failure of vision to develop areas, they are usually left in place after
properly, frequently due to strabismus or deployment, where they kill, maim, or
anisometropia; sometimes called ‘lazy eye.’ blind thousands of civilians annually.
AMD Age-related macular degeneration. aphake A person with unilateral or
See macular degeneration. bilateral aphakia.
ametropia A refractive error. aphakia The condition of the eye without
a lens, usually as a result of cataract
anesthesia Loss of sensation, especially
extraction.
absence of pain, after administering an
anesthetic drug. Injury to sensory nerves aphakic spectacles Highly convex (plus)
may also produce anesthesia. lenses.
angle Junction of the iris and the cornea APL Antipersonnel landmine.
in the anterior chamber.
applanation A form of tonometry in which
aniseikonia A difference in the size of the force required to flatten a small area of
ocular image between the two eyes, caused the central cornea is measured.
by aphakia in one eye only.
aqueous (aqueous fluid; aqueous
anisometropia A condition where there humor) The consistency of water that fills
are two or more diopters of difference in the anterior chamber, produced by the
the refractive error between the two eyes. epithelium of the ciliary body.
antagonist A drug that neutralizes the argon laser Laser instrument used to
action of another substance. treat diabetic retinopathy (pan retinal
photocoagulation), primary open-angle
anterior chamber (AC) Space between
glaucoma (trabeculoplasty), acute angle-
the cornea and the iris that is filled with
closure glaucoma (iridotomy), and other
aqueous fluid.
intraocular disease states.
anterior segment The front part of the
Arlt’s line Characteristic tarsal eyelid scar
eye, including the cornea, surgical limbus,
in trachoma.
anterior chamber, iris, and lens with its
attachments (zonules). asymptomatic Without symptoms.
anterior uveitis Inflammation (uveitis) of asthenopia Mild ocular discomfort often
the iris (iritis) or ciliary body (cyclitis), or due to refractive error in healthy eyes;
both (iridocyclitis). commonly called ‘eye strain.’
antimetabolite Any of various drugs used astigmatism (Greek, ‘without a point’)
in chemotherapy of cancer; in glaucoma Refractive error due to a non-spherical
filtering surgery, one of several drugs that corneal surface.
may be used to intentionally delay healing
autoclave A metal chamber equipped
and closure of the surgical fistula that is
to use steam or gas under high pressure
being used to drain aqueous fluid and thus
and temperature to sterilize surgical
to lower intraocular pressure.
instruments.
antipersonnel landmine (APL) In-ground
explosive weapon, triggered by pressure or
vibration. Used to deny access to large
