P bli H lth O hth l Public Health Ophthalmology l P Prevention - - PowerPoint PPT Presentation

Community ophthalmology y p gy

P bli H lth O hth l l Public Health Ophthalmology P ti f Bli d Prevention of Blindness P i Primary eye care Community eye care

Community ophthalmology y p gy

5 questions of blindness

• 1. What is blindness? DEFINITION
• 2. How many are blind? MAGNITUDE
• 3. Why are people blind? ETIOLOGY
• 4. Why the number increase? TRENDS

5 What can we do ? CONTROL

• 5. What can we do ? CONTROL

Community ophthalmology y p gy

• WHO. Classification of visual impairment

Snellen Visual Acuity Normal 6/6 to 6/18 Visual impairment < 6/18 to 6/60 Severe Visual impairment < 6/60 to 3/60 Blind < 3/60 to N L P Blind < 3/60 to N.L.P.

Community ophthalmology y p gy

พรบ. ฟนฟูสมรรถภาพคนพิการ

ลักษณะความพิการ ระดับที่ สายตา ลานสายตา

ื ( ) ๖/ ๘ ึ ๖/๖

ึ

สายตาเลอนลาง (VA) ๑ ๖/๑๘ ถึง ๖/๖๐ < ๓๐ ถึง ๑๐ องศา สายตาพิการ (VF) ๒ < ๖/๖๐ ถึง ๓/๖๐ ( ) ตาบอดขั้นที่๑ ๓ < ๓/๖๐ ถึง ๑/๖๐ < ๑๐ ถึง ๕ องศา ้ ่ ตาบอดขันที๒ ๔ < ๑/๖๐ ถึง PL < ๕ องศา ตาบอดขั้นที่๓ ๕ N L P ตาบอดขนท๓ ๕ N.L.P.

Community ophthalmology y p gy

ตัวอยาง ตวอยาง ๑) ผปวย ตอกระจกทั้ง๒ขาง สายตามองเห็นแคนับนิ้ว ทั้ง๒ขาง ) ู ๒) ผูปวยตอหินทั้ง๒ขาง มองเห็นเฉพาะตรงกลาง VA 20/20 ทั้ง๒ ขาง ป ั ิ  ั  ั  ไ  ็ ๓) ผูปวยอุบัติเหตุรถยนต หลังผาตัดแลว ตาขวามองไมเห็น ตา ซายปกติ ๔) เด็กตาขุนมัวมาตั้งแตเกิด มองไมเห็นตัวหนังสือเลย

Community ophthalmology y p gy

Prevention of Blindness Prevention of Blindness situation 50 m Blind in 2000 worldwide 1-2% in the third world 0.31% in Thailand estimation 180,000

Community ophthalmology y p gy

Magnitude of Global Blindness

60 70 40 50 20 30 million 10 1975 1984 1990 1995 2000 2020

Community ophthalmology y p gy

Distribution of total global blindness g

America&Europe rest of Asia India China Africa Africa

Community ophthalmology y p gy

Worldwide blindness d

good poor

Blindness rate 0.1 - 0.4 % 0.5 -1.5 % Major causes AMD. Cataract

Glaucoma Glaucoma Glaucoma Glaucoma

• DR. Trachoma/scar

C it l di O h i i Congenital disease Onchocerciasis Hereditary disease Vit. A deficiency

Location Posterior segment Anterior segment % Avoidable 20% 80% % Avoidable 20% 80% Etiology poorly understand usually well known

Community ophthalmology y p gy

Cause of Blindness developing country preventable/undertreatment partial developed (0.4-0.65%) developed complicated/untreatable

Community ophthalmology y p gy

Cause of worldwide blindness, year 2000 disease blind (million) % trend disease blind (million) % trend

# Cataract 25 50 # Glaucoma 8 16 # Glaucoma 8 16 # DR. 3 6 # AMD. 2 4 # Corneal scar/Trachoma ? 5 10

• Vit. A deficiency ? 0.5 1

Onchocerciasis ? 0.5 1 Leprosy ? 0.5 1 Refractive error 2 4 Refractive error 2 4 Childhood blindness 1 2 Trauma 1 2 Trauma 1 2 Other 1.5 3

Community ophthalmology y p gy

Cause of Blindness in Thailand (1994) ( )

Cataract 74.65% Corneal opacity 4.93% Glaucoma 3.52% Globe disorder 3.52% Macular degeneration 2.82% Vascular retinopathy 2.11%

Community ophthalmology y p gy

Blindness Survey Prevalence of Blindness Most com m on Prevalence of cataract Survey Blindness com m on cause cataract 1 st Survey ( 1 9 8 3 )

1.14% Cataract 47%

( 1 9 8 3 ) 2 nd Survey ( 1 9 8 7 )

0.58% Cataract 73%

( 1 9 8 7 ) 3 rd Survey ( 1 9 9 4 )

0.31% Cataract 74%

( 1 9 9 4 ) 4 th Survey ( 2 0 0 6 )

0.59%

(LV = 1 57% )

Cataract 52%

( 2 0 0 6 ) (LV = 1.57% )

Community ophthalmology y p gy

Visual im pairm ent W eighted Prevalence Estim ated total Visual im pairm ent ( % ) num bers Low Vision one eye 2 18% 1 369 362 Low Vision one eye 2.18% 1,369,362 Low Vision both eyes 1 .5 7 % 9 8 7 ,9 9 3 Blindness one eye 1 59% 996 040 Blindness one eye 1.59% 996,040 Blindness both eyes 0 .5 9 % 3 6 9 ,0 1 3 Bli d l i i Blindness one eye, low vision one eye 0.39% 242,562 Total 6 .3 2 % 3 ,9 6 4 ,9 7 0 6 .3 2 % 3 ,9 6 4 ,9 7 0

Community ophthalmology y p gy

Cause of Visual Impairment (Blind both Eye)

Di b ti ti th Diabetic retinopathy 2% Optic atrophy 4% Age-related macular degeneration Cataract 52% degeneration 7% Glaucoma Refractive errors, Glaucoma 10% uncorrected aphakia 2%

Community ophthalmology y p gy

Cause of Visual Impairment (Low vision both eyes) p ( y )

Significant pterygium 3% Diabetic retinopathy 5% Age-related macular degeneration 4% 3% 4% Glaucoma 10% Cataract 57% Refractive errors, uncorrected aphakia 14%

Community ophthalmology y p gy

Increasing number of blindness

increase in population increase in life expectancy p y inadequate eye care service

age year2000 future % increase

0-4 years 900 900 0 0 4 years 900 900 0 5-19 years 1300 1300 0 20-64 years 3400 5000 50 >64 years 400 800 100 y total 6000 8000 33

Community ophthalmology y p gy

44 50 30 40 /1000 19 20 prevalence/ 0.8 1 10 p 0-14 15-44 45-59 60+

Community ophthalmology y p gy

Primary prevention Incidence 6 million /years Secondary prevention Prevalence Secondary prevention 50 million blind Sight restoration Mortality Sight restoration

1 million / year

Mortality

4 million / year

Increase of

1 million/year

Community ophthalmology

Healthy

y p gy

Birth control Health Di Healthy general population Birth control promotion Disease Prevention

Chronic illness Impairment

Increase life expectancy Medical care

death

Increase quality of life More education Handicap Rehabilitation More wants More etc. Handicap Rehabilitation

Community ophthalmology y p gy

Primary prevention Promotion of Community Immune Environmental Health Health Management

Community ophthalmology y p gy

Secondary prevention Secondary prevention screening criteria screening criteria

morbidity/mortality prevalence natural Hx y y p effective Rx benefit of early Rx appropriate test

Community ophthalmology y p gy

Strategy approach to control of blindness primary prevention prevent from occuring p y p p g

Vitamin A deficiency good nutrition Trachoma good water & sanitation Trachoma good water & sanitation Rubella & Measles immunization

secondary prevention prevent loss of vision from disease secondary prevention prevent loss of vision from disease

Cataract surgery when vision is decrease Glaucoma sight prevention; surgical/medical Diabetic retinopathy sight preserving LASER treatment tertiary prevention restore vision to a blind person Cataract sight restoration in bilateral blinding cataract Corneal scar keratoplasty Low vision service visual rehabilitation

Community ophthalmology y p gy 4 groups of blindness community control programs g p y p g

• 1. Priority&majority highly cost- effective intervention

Cataract & significant refractive error (50-67%) Cataract & significant refractive error (50 67%)

• 2. Focal blinding disease cost-effective, prevention&treatment

Trachoma, Vitamin A deficiency etc (10-15%) Trachoma, Vitamin A deficiency etc (10 15%) Primary health care & community eye worker training

• 3. Complicated disease effective early treatment (by specialist)
• 3. Complicated disease effective early treatment (by specialist)

Glaucoma, Diabetic retinopathy etc (20%) community screening program & referral system community screening program & referral system

• 4. Blinding disease no effective prevention&treatment

aged related macular degeneration, retinitis pigmentosa aged e ated acu a dege e at o , et t s p g e tosa congenital ocular abnormalities

Community ophthalmology y p gy

Blinding eye diseases

CATARACT TRACHOMA GLAUCOMA DIABETIC RETINOPATHY ONCOCERCIASIS VITAMIN A DEFICIENCY DIABETIC RETINOPATHY VITAMIN A DEFICIENCY Occur everywhere affect individual Focal disease affect community affect individual affect mainly adult requires surgery affect community start in children requires medicine requires surgery need an eye doctor equ es ed c e does not requires an eye doctor HOSPITAL BASE COMMUNITY BASE

Community ophthalmology

Primary eye care in the community

Screening Simple Medication

y p gy

P i h it l Health voluntier

Screening Simple Medication

Primary care hospital Midlevel health personel Health voluntier

Screening Simple Medication & treatment

Case refer Academic support Midl l h lth Seconary care hospital Ophthalmologist

Simple Surgery Research

Midlevel health personel Ophthalmologist Case refer Academic support

Research

Tertiary care hospital pp

Complicated Surgery Research

Subspecialty Ophthamologist Resident

Research Policy setting

Community ophthalmology

Comprehensive Eye Care

y p gy

Comprehensive Eye Care

Pr Prov

• vin

incial al Hosp Hospit ital al

Planning &

Provincial Provincial Hos Hospit ital Ey Eye Un e Unit

Planning & Management

Curat rative S ve Servi rvices es Comm Communi unity Hos Hospital P i P i C U i Primar mary Car are e Unit Co Comm mmuni unity

Pr Prevention evention & & Pr Promotion

• motion

Dec 08 Phnom Penh 17

Community ophthalmology y p gy 1998 ประชากร จักษุแพทย อัตราสวน กทม./ปริมณฑล 8,619,340 290 29,722 ภาคกลาง 8 928 252 82 108 882 ภาคกลาง 8,928,252 82 108,882 ภาคตะวันออก 4,180,837 34 122,966 ใ  ภาคใต 8,696,590 49 177,481 ภาคเหนือ 10,048,976 53 189,603 ภาคเหนอ 10,048,976 53 189,603 ภาคอีสาน 21,404,751 60 356,746

Community ophthalmology

Distribution of ophthamologist in Thailand

y p gy

Survey in 2007 63m population 803 ophthalmologist

area

• phthalmologist

ratio gov pri total Bangkok 244 129 373 1:15171 Central 93 18 111 1:101691 Eastern 42 9 51 1:73230 Eastern 42 9 51 1:73230 Southern 66 12 78 1:98124 Northern 70 9 79 1:136781 Northeastern 91 10 101 1:211169 Total 606 187 793 1:78711

Community ophthalmology y p gy

Blind person years, four major condition

diti ti t d N d ti bli d condition estimated No ave. duration blind person years cataract 25 x 5 = 125 1 glaucoma 8 x 8 = 64 3 DR 3 x 5 = 15 4 child blindness 1.5 x 50 = 75 2

20 25

100 120 140

5 10 15

40 60 80

5 cataract glaucoma DR child blindness

20 cataract glaucoma DR child blindness

Community ophthalmology y p gy 6 step of problem solving paradigm

• 1. Define the problem

2 Measure the magnitude

• 2. Measure the magnitude
• 3. Define the key determination

y

• 4. Decision of intervention
• 5. Set policy
• 6. Implement/evaluation

Community ophthalmology y p gy

Key determination Biological factor genetic, age, microbiology, disease genetic, age, microbiology, disease Social/culture/behavior knowledge, fear, life style Environment/occupation Environment/occupation geographic, manpower, barrier

Community ophthalmology y p gy Health system evaluation Equity/Equality Quality Quality Efficiency Social acceptance Relevant

Important things are not visible to the eye. p g y

By a Fox (in “Little Prince”)

All the lonely people, y p p , where do they come from? All the lonely people, where do they belong? where do they belong?

“Eleanor Rigby”

( I can ) change the world ( I can ) change the world.

• E. Clapton

Community ophthalmology y p gy

problem solving paradigm for blinding cataract

• 1. Define the problem What is blinding cataract?
• 2. Measure the magnitude How many blinding catract
• 2. Measure the magnitude How many blinding catract

are there in Thailand?

• 3. Define the key determination What is the risk?
• 4. Decision of intervention What will we do?
• 5. Set policy How will we support it?
• 6. Implement/evaluation How does it work?

Community ophthalmology y p gy

Blinding cataract Definition Definition Blinding 10/200 g Cataract lens opacity must R/O other cause of blindness Magnitude prevalence (backlock) incidence incidence

Community ophthalmology y p gy

Key determination for cataract Biological factor age, disease(DM), trauma, congenital age, disease(DM), trauma, congenital Social/culture/behavior knowledge, attitude, life style, socioeconomic Environment/occupation Environment/occupation geographic, manpower, barrier, health system

Community ophthalmology y p gy

Cataract Decision of intervention

Screening of cases Screening of cases community base/hospital base health voluntier/health personel R f l Referal system routine/fast tract Operation satelite hospital/provincial hospital routine/campaign routine/campaign ECCE/PE with IOL

Community ophthalmology y p gy

Cataract Decision of intervention

Education Education mass media patient i i l training personel Follow up Ophthalmologist requirement ?

Community ophthalmology y p gy

Strategies for finding the cataract blind

• 1. Wait for patients

Surgical camp

• 2. Surgical camp in community

Screening clinic

• 3. Screening clinic in community

4 S d i l t llit h it l Satellite hospital

• 4. Secondary surgical satellite hospital

Community based referral

• 5. CBR case detection in community

Community ophthalmology y p gy

Cataract policy setting Target setting Target setting waiting time blinding cataract operation rate blinding cataract operation rate Support doctor fee per case private/government equipment IOL manpower Ophthalmologist, nurse, personel, etc. p p g , , p , complication management special supporting group ? special supporting group ?

Community ophthalmology y p gy

Cataract program implement & evaluation Registration/report waiting time blinding cataract operation rate register of blindness g Quality assurance good health care system good health care system audit O h ff Other effect

• ther health care system

personel

Community ophthalmology y p gy

Ophthalmic screening (general) p g (g ) asymtomatic early/late damage asymtomatic early/late damage central/peripheral vision central/peripheral vision monocular/binocular monocular/binocular l o w / h i g h r i s k a g e l o w / h i g h r i s k a g e

Community ophthalmology y p gy

Ophthalmic screening (special purpose) p g ( p p p ) student human right student human right driver/pilot safety driver/pilot safety worker efficiency worker efficiency etc etc.

Community ophthalmology y p gy

Normal visual development

intermittent fixation at birth nearby face fixation 2-3 month smooth follow near movement 3 month full accomodation 3-4 month

• nset of stereopsis 3-5 month

well distant fixation 6 month subjective VA test 3 year adult-type VA test 5-6 year

Community ophthalmology y p gy

VA for 6 month children C entering S teady S teady M aintain M aintain

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

High risk children High risk adult g g prematurity RD, severe ocular trauma prematurity RD, severe ocular trauma family Hx family Hx family Hx family Hx intrauterine infection one eye, age > 65 intrauterine infection one eye, age > 65 systemic disease systemic disease systemic disease systemic disease

Community ophthalmology y p gy

มีค ๒๕๔๗ มีการติดเชื้อตาแดงในneonatal ward ทานจะทําอยางไร

Community ophthalmology y p gy

๒๕๓๓ หยอด formalin ลงในตาเด็กแรกเกิด ๒๕๔๘ หยอด silver nitrate แลวมีsevere ๒๕๔๘ หยอด silver nitrate แลวมsevere reaction & corneal scar How do we do to solve this problem? p

Community ophthalmology y p gy

Ophthalmia Neonatorum

cause GC / Chlamydia /Chemical / Herpes simplex prophylacis 1% Silver nitrate (solution) 1% Tetracyclin / 0.5% Erythromycin (ointment) Providone iodine (solution) Providone iodine (solution) ceftriaxone 125mg Erythromycin base 50mg/kg/day x14 day

Community ophthalmology y p gy

Community ophthalmology y p gy

Amblyopia y p refractive error / strabismus /other refractive error / strabismus /other

1-4 % in population occlusion therapy preschool age 4-6 year visual screening VA / stereopsis

Community ophthalmology y p gy

Community ophthalmology y p gy

Amblyopic treatment

Community ophthalmology y p gy

Xerophthalmia Vitamin A deficiency

dry eye /corneal perforation Measle nutrition breast feeding immunization vitamin A supplement ? regular/ periodic

Community ophthalmology y p gy

Keratomalacia bitot’s spot Keratomalacia bitot s spot

Community ophthalmology y p gy

Trachoma

chlamydial infection poor environment/water supply superimpose bacterial infection flies i i i i / i / lid ulcer trichiasis / entropian corneal ulcer/ scar

Community ophthalmology y p gy

Trachoma Rx ineffective, long course, complication, cost

topical tetracyclin / erythromycin bid x 5d/m x 6 month aim severity population control surgical correction of entropian

Community ophthalmology y p gy

Community ophthalmology y p gy

Retinopathy of Prematurity p y y

prematurity / oxygen therapy vasoconstriction neovascularization traction RD retrolental fibroplasia high risk group high risk group BW < 1500 gm GA < 32 week

• xygen Rx > 4 hour

Community ophthalmology y p gy

Retinopathy of Prematurity

dilated fundus examination as soon as possible Threshold ROP stage 3 plus >3 hour cont. / 8 hour sum. Cryotherapy / laser treatment retinal surgery follow up look for high myopic astigmatism glaucoma follow up look for high myopic astigmatism, glaucoma amblyopic treatment amblyopic treatment

Community ophthalmology y p gy

ROP 1 2 3 4 3 4

Community ophthalmology y p gy

ROP

Community ophthalmology y p gy

Glaucoma ocular hypertension

increase IOP normal tension glaucoma

• ptic nerve damage

physiologic large cupping visual field defect POAG PACG SOAG SACG

Community ophthalmology y p gy

Glaucoma Glaucoma

Screening test Screening test IOP Schiotz / applanation tonometry

• ptic nerve cupping non - stereopsis / stereopsis

visual field confrontation / Goldman perimetry / CTVF

Community ophthalmology y p gy

Glaucoma

High risk group > 40 year old DM, thyroid HT IHD hi h i HT, IHD high myopia family history of POAG y s o y o O G angle recess glaucoma steroid induced glaucoma

Community ophthalmology y p gy

normal

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Goldman ‘s perimetry

Community ophthalmology y p gy

CTVF

Community ophthalmology y p gy

Retinal vascular disease Retinal vascular disease

Diabetic retinopathy Diabetic retinopathy DM type1 5year after Dx DM type2 at time of Dx annually dilated fundus examination till Dx of DR

Community ophthalmology y p gy

Diabetic retinopathy

lif ti / lif ti non - proliferative / proliferative clinical significant macular edema ( CSME ) ? clinical significant macular edema ( CSME ) ? LASER Rx PMP PRP vitrectomy

Community ophthalmology y p gy

Community ophthalmology y p gy

CSME CSME

Community ophthalmology y p gy

Aged macular degeneration Aged macular degeneration

central scotoma blur vision metamorphopsia central scotoma blur vision metamorphopsia non - exudative / exudative screening test Amsler’s grid nutritional support? LASER Rx stop smoking

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Ocular trauma

workplace recreation/sport home transportation protective device environment law individual screening test

Community ophthalmology y p gy

Community ophthalmology y p gy

Disorder change in anatomy/physiology of an

• rgan system
• rgan system

Impairment functional change in organ system Disability skill / ability of the individual Handicap the societal/economic consequence of a

disability disability

Community ophthalmology y p gy

• the organ the person

disorder impairment disability handicap

anatomical change functional change skill /ability social /economic

• c c

ge u c o c ge s / b y soc /eco o c

inflammation visual acuity reading extraeffort atrophy visaul field daily living dependence scar color vision mobility

Community ophthalmology y p gy

Disorder Impairment Disability Handicap

Medical/surgical intervention Visual aids adapted equipment Social intervention training intervention adapted equipment training counseling education education

Community ophthalmology y p gy

Visual rehabilitation medical visual aid orientation/mobility training y g educational blind/low vision special school p social behavior, recreation, sex etc , ,

• ccupational

p

Community ophthalmology y p gy

Visual field orientation / mobility Visual field orientation / mobility 51-70 degree normal 31-50 degree normal, use more scanning 11-30 degree near-normal, constant scanning 11 30 degree near normal, constant scanning 6 -10 degree slower, require scanning & cane 3 - 5 degree use cane for detection ,vision for identification less unreliable, use blind mobility skill NLP no visual orientation NLP no visual orientation

Community ophthalmology y p gy

mobility training t li i i 3/200 ith 50 d VF traveling vision 3/200 with > 50 degree VF < 20 degree VF orientation problem < 20 degree VF orientation problem 1) sight guide 2) long cane 3) dog guide 4) electronic mobility device 4) electronic mobility device

Community ophthalmology y p gy

การนําทางคนตาบอด  ํ  ํ ั  ็  ๑) ผูนําทาง หุบแขนขางลําตัว งอขอศอกเล็กนอย ๒) ผตาม ใชมือจับที่เหนือขอศอก หางผนํา๑/๒กาว ๒) ผูตาม ใชมอจบทเหนอขอศอก หางผูนา๑/๒กาว ๓) ผูนําทาง เดินพอใหผูตาม สามารถเดินตามทันได ู ู ๔) ผูนําทาง ขยับขอศอกไปดานหลัง เพื่อเปนสัญญาณ วา ทางแคบลง มีปร ต วา ทางแคบลง มประตู ๕) ผนําทาง คอยบอกวามีสิ่งสังเกตที่สําคัญ อยที่ใด ๕) ผูนาทาง คอยบอกวามสงสงเกตทสาคญ อยูทใด ๖) เมื่อจะปลอยใหผูตามอยูตามลําพัง ควรไวที่ติดเกาอี้ หรือ กําแพง

Community ophthalmology y p gy

Cane long cane foot to 1 1/2 inch above sternum bottom contact feed back scanning no forewarning of overhead obstacles no forewarning of overhead obstacles white cane sign of visual impairment g p

Community ophthalmology y p gy

dog guide extensive training maturity & intelligence 18 60 d h lth d h i d age 18 -60, good health, good hearing and no residual vision

German shepherd, Golden/Labrador retriever and Boxer

F l d f d Female dogs are preferred.

Community ophthalmology y p gy

Low vision care 1) diagnosis 2) di l & i l t t t 2) medical & surgical treatment 3) analysis of visual function 3) ys s o v su u c o 4) problem discussion 5) low vision examination 6) h i l 6) psychosocial assessment 7) provision of a range of equipment 7) provision of a range of equipment

Community ophthalmology y p gy

low vision care 8) d ti & i t ti f ti l d i 8) recommendation & instruction of optical device 9) prescription 9) prescription 10) dispensing 11) patient education 12) vision & other rehabilitation service 13) access to available funding sources 13) access to available funding sources 14) continuing eye care 15) training & continuous education

Community ophthalmology y p gy

Range of VA reading ability general ability 20/12 - 20/25 normal normal c reserve 20/30 - 20/60 shorter distance normal s reserve 20/80 - 20/160 near - normal near normal require aids 20/80 - 20/160 near - normal near normal require aids 20/200 -20/400 slower than normal slower than normal 20/500 -20/1000 limited reading some task c aids 20/1250 20/2500 li bl f k b i 20/1250 -20/2500 unreliable few task, use substitute NLP not possible no task p

Community ophthalmology y p gy

adaptive low vision device 1) relative size device ) i /i i i 2) light/illumination control 3) posture/positioning device 3) posture/positioning device 4) writing /communication device 5) medical assistive device 6) mobility assistive device 7) sensory substitution device 7) sensory substitution device

Community ophthalmology y p gy

sensory substitution device A dit b tit t Auditory substitute talking book/device, computer program etc. talking book/device, computer program etc. Tactile substitute Braille, Nonbraille Vision substitute neural prosthesis neural prosthesis

Community ophthalmology y p gy

Braille 6 raised dot 3 high / 2 wide 6 raised dot 3 high / 2 wide grade 1 letter g grade 2 contraction/abbreviated word grade 3 personal note taking b tt l i i hild better learning in children 100 word/ min but talking book 175 word/min 100 word/ min but talking book 175 word/min

Community ophthalmology y p gy

Optical aids Hand-held magnifiers Stand magnifiers Ill i t d ifi R di l Illuminated magnifiers Reading glasses Loupes and visors Reading telescopes

• upes d v so s e d g e escopes

Telescopes Video magnifiers Prisms Reverse telescopes

Community ophthalmology y p gy

Hand - held magnifiers inexpensive / familiar / easy to use normal working distance i i must be held steadily at an exact distance limited viewing field make slow reading limited viewing field make slow reading

Community ophthalmology y p gy

Community ophthalmology y p gy

Stand magnifiers stand hold the lens steadily at fixed / proper distance i i i f use with reading glasses to obtain best focus

• therwise same as Hand - held magnifiers
• therwise same as Hand held magnifiers

Community ophthalmology y p gy

Illuminated magnifiers build in light i S ifi either Hand - held or Stand magnifiers AC / batteries / rechargeable batteries AC / batteries / rechargeable batteries incandescent, halogen, or fluorescent

Community ophthalmology y p gy

Reading glasses leave the hands free i fi f i widest field of view very close working distance very close working distance training program

Community ophthalmology y p gy

Loupes & Visors small field of view small field of view headgear cumbersome g usually inexpensive can be flipped in or flipped out

Community ophthalmology y p gy

Reading telescope difficult to use

high magnification but constrict field /shallow depth of field high magnification but constrict field /shallow depth of field

arm’s length working distance

mounted in lower part of a pair of glasses bioptic telescope mounted in middle part of a pair of glasses easier to use

multifocal turning end / reading cap multifocal turning end / reading cap

Community ophthalmology y p gy

Telescope the only visual aids for distance vision l / bi l monocular / binocular Galilean (distance) / Keplerian ( closer) G e (d s ce) / ep e ( c ose ) small field of view / must be held very steadily magnification >8X are not routinely recommended

Community ophthalmology y p gy

Monocular telescope Monocular telescope

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Video magnifiers g small video camera with a zoom closed-up lens connected with a monitor make the image as large as necessary make the image as large as necessary reverse polarity may be more contrast i expensive

Community ophthalmology y p gy

Community ophthalmology y p gy

Aids for visual field loss Prisms expand VF awareness in loss side vision f i / di i ti d t i i confusing / disorienting, need training Reverse telescopes Reverse telescopes smaller magnification but larger field

Community ophthalmology y p gy

Relative size devices Large print sharp edge sharp edge at least 2.7 mm. height letter 18 point type g p yp high contrast & good opaque paper Large print typewriters & computer

Community ophthalmology y p gy

Lighting & illumination control Sunlight natural but control problem Fluorescent lower contrast but fewer shadow cooler Fluorescent lower contrast, but fewer shadow, cooler Incandescent more contrast, more shadow, less scatter Neodymium sunlight improve reading performance Halogen UV may be phototoxic, should be caution Rheostat use to control light source Rheostat use to control light source

Community ophthalmology y p gy

Filter control glare l t l l di t ti color neutral gray no color distortion green very little effect on color perception g y p p yellow increase contrast by absorbing scattering blue light

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Occupational health health assessment ) & 1) pre & post employment exam 2) exam for hazard exposure 2) exam for hazard exposure 3) treatment as family doctor 4) emergency treatment at workplace

Community ophthalmology y p gy

Occupational health Advisory service

1) prevention of occupational disease 1) prevention of occupational disease 2) forensic medicine 3) di l t f k / i t 3) medical aspect of work process / environment 4) prevention of common non-occupational disease 5) t i i fi t id 5) training first aid 6) plan for major disaster

Community ophthalmology y p gy

Eye protection program 1) environment survey 2) vision screening 3) implementation of the program 4) maintenance of the program

Community ophthalmology y p gy

Environment survey

chemical

identify occupational hazard

chemical physical

control hazard

biological

ergonomic emergency first aid device emergency first aid device accident record accident record

Community ophthalmology y p gy

advantage of vision screening in industry

1) l i f l i bl 1) selection of personnel suitable 2) identify visual disable transfer/rehabilitation 3) improve relationship 4) improve visual efficiency increase productivity 4) improve visual efficiency increase productivity

reduce accident reduce visual fatiguing

5) appropriate compensatory claim 5) appropriate compensatory claim

Community ophthalmology y p gy

Implementation of the program

1) elimination / control of ocular hazard

2) provision of eye protectors ) p y p 3) hazard zoning with warning sign 4) first aid facility 4) first aid facility 5) lens cleaning station 6) safety committee 6) safety committee 7) education /training

Community ophthalmology y p gy

Prevention & control strategy

1) specification 2) substitution 3) segregation 4) local extract ventilation ) ) 5) dilution ventilation 6) personal hygiene 7) reduce time exposure 8) personal protection 7) reduce time exposure 8) personal protection

Community ophthalmology y p gy

Safety sign

type prohibition mandatory warning safe condition meaning STOP MUST CAUTION way to go meaning STOP MUST CAUTION way to go symbol

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy

Community ophthalmology y p gy