AND HOW CAN I PUT IT INTO PRACTICE? The See to Learn Program CONAVIP (The National VISION 2020 Committee of Paraguay) CONAVIP * Ministerio de Salud Publica * Sociedad Paraguaya de Oftalmologia * Universidad Nacional de Asuncion * Instituto de Prevision Social * Hospital de la Fuerzas Armadas * Fundacion Vision * Fundacion Banco de Ojos * Fundacion Santa Lucia * Lions International * PLAN International Consultants: IAPB - PAHO WHO1 estimates that the number of persons with visual impairment in the world, when conditions caused by uncorrected refractive error are included, is much greater than that usually reported using visual acuity (VA) in best corrected vision. Dandona2 suggests that, if uncorrected refractive error is considered, there are some 259 million persons with impaired vision in the world, including 42 million who are blind (VA less than 20/400 in the better eye) and that these numbers, rather than the frequently cited figures of 161 million with impaired vision and 35 million blind, are the ones that should be used in future planning of the VISION 2020 program. Uncorrected refractive error is the most common cause of impaired vision in the world. WHO1 also estimates that there are 1.4 million children in the world who are blind. In Latin America, Chile has reported a prevalence of uncorrected refractive error of 15.8% in children 5 to 15 years of age3, and it is very probable that the situation is worse in other countries of the region. Visual handicaps caused by these problems can affect the quality of education, personal development and employment opportunities. Additionally, the lack of a diagnosis of low vision or blindness caused by refractive error, can lead to the unnecessary inclusion of these children in schools for the blind.4 We do not have data on the costs of this type of blindness, but it is reasonable to assume that it constitutes an important economic burden to society. This is the reason for the importance of the detection of refractive error in children, which can be done by routine examination of patients by making regular visits, or through population-based screening campaigns. The latter method is more appropriate for developing countries, in which, a large part of the population often has no access to eye-health services. In regards to children, in countries with an adequate rate of literacy and school attendance, screening can be done in schoolchildren. In cases where these rates are inadequate, community programs are necessary, including house-to-house visits, by trained personnel who can identify vision problems and refer the cases detected to the appropriate healthcare professional. This method, when conducted thoroughly, implies a greater investment of human and financial resources. In Paraguay, with the support of Plan International, an NGO that works with needy children, CONAVIP has begun a program called Ver para Aprender, or “See to Learn”. Objective: To detect and treat refractive error and reduce the prevalence of blindness due to this cause, in rural school-age children, in four of the nation's departments (provinces). Actions Taken to Reach the Objective 1. Agreement signed between CONAVIP and the Ministry of Education and Culture of Paraguay. 2. Agreement signed between CONAVIP and Plan International, permitting the purchase of the ophthalmological equipment needed to carry out the campaign. The agreement also financed a per diem for the medical professionals involved, as well as paying for strabismus and traumatic or congenital cataract surgeries. 3. Visits to school and district officials. 4. Training for teachers, parents, and volunteer health promoters (VHPs), in measuring the visual acuity of the children and referring those with problems. 5. Exams and corrective prescriptions by ophthalmologists for the referred children. 6. Providing eyeglasses to children who needed them. 7. Performance of surgery for strabismus and traumatic or congenital cataract for patients needing them. Snellen charts and forms to be filled out by the teachers, parents, and ophthalmologists were prepared for these activities. The program measured visual acuity using Snellen Tumbling E Charts at 6 meters distance, using both eyes opne. Children tested should read a minimum of 50% of the 20/40 line (minimum of 4 of 6 letters). Fig.1: Snellen Chart Figure 2: Referral Card To refer a child with vision of less than 20/40, the teacher or volunteer, should fill out a referral card for the ophthalmologist and a notification card for the parents. Figure 3: Parent Notification Card Finally, the ophthalmologist, after examining the child and when significant refractive error is found, he/she prescribes the correction needed, filings out a form, recording the findings and the treatment indicated. Figure 4: Ophthalmological Card During the first part of the program, schoolchildren from four of the country's departments who had not previously had access to this type of healthcare, were seen in a mass screening campaign. Some 2,640 teachers, parents, and volunteer health promoters (VHPs) were trained. A total of 78,045 children were screened and 8,216 (10.5%), were referred to an ophthalmologist. A response rate of 84.8% (n: 6,965) was obtained, a figure we consider very good. Fourteen percent (n: 990) of those examined, comprising 1.3% of all children screened, received eyeglasses. Surgery was required by 0.3% (n: 261). District No. of VHPs No. of No. of No. of No. of No. of teachers, children children children children children and parents screened referred for treated receiving operated exams glasses on Caaguazu 1,751 53.025 4.495 3.445 426 127 Cordillera,709 25.020 3.631 3.520 564 134 Guaira, and Paraguari TOTAL 2.460 78.045 8.216 6.965 990 261 Table 1. Summary of personnel trained and children screened and treated. Notably, 8.5% of the children screened from the Department of Caaguazu were referred, with a 76.9% response rate, whereas, the other departments referred 14.5% of the children, with a 96.6% response rate. We believe that this was caused by the desire of the parents to have the children seen by an ophthalmologist, not merely by their teachers, a fact which obliged us to reinforce the training of the teachers, to reduce unnecessary referrals. Following this first phase, the See to Learn Program will now continue with the support of CBM. It will be implemented for three years in the same areas, examining children entering the school system, that is to say, those in kindergarten, or 1 st grade. Also those in 6th, and 7th grades, to detect any myopic shift in refraction, based on what was reported by Maul et al. 3 Children who had previously received eyeglasses will also be evaluated to verify their compliance in using them, reasons for any non-compliance, and whether this has affected their schoolwork. What Have We Learned so Far? 1. Training of teachers, parents and health promoters must be ongoing, not limited to a single instance, because what was learnt becomes forgotten and interest diminishes without periodical reinforcement. 2. Teachers and parents must be helped to understand, that it is not necessary for all of the children to see an ophthalmologist, since that unnecessarily burdens the program. 3. The idea of treating all comers without charge needs to be reevaluated, since it stimulates participation by those who are not needy. It might be useful to offer attention to adults at the same time as the screening, charging adults at least a small fee and also obtain funds through the sale of eyeglasses. 4. Inclusion of instruction on how to take Visual Acuity in the curriculum for teacher education is necessary, in order to build their commitment to children's eye health. 5. It has been demonstrated that it is possible to bring professional medical care to rural areas of the country through joint efforts by diverse institutions. Professionals from all ten of CONAVIP's member institutions participated in the program. 6. One important impediment to carrying out the program smoothly was the political situation in Paraguay . The intended schedule could not be kept due to several teachers' strikes brought on by the fact, that it was an election year, which made it an opportune time to seek increased pay. We continue learning, and intend to extend the program to the rest of the country. It will be hard work, but we believe it is of vital importance to reduce this type of treatable blindness, among the children of our country. Miriam Rafaela Cano, MD, MSc CEH President of CONAVIP, the National VISION 2020 Committee in Paraguay firstname.lastname@example.org References: 1. WHO: http://www.who.int/blindness 2. Dandona L. and Dandona R. What is the global burden of visual impairment? BMC Medicine 2006, 4: 6 3 . Maul et al . Refractive Error Study in Children: results from La Florida , Chile . Am J Ophthalmol. 2000 Apr; 129(4):445-54 4. Rahi JS et al . Childhood blindness in India : causes in 1318 blind school students in nine states. Eye , 1995, 9 : 545–550.