Providing spectacles in developing countries
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7158.551 (Published 29 August 1998) Cite this as: BMJ 1998;317:551All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I am in complete agreement with Andrew Potter about the importance of providing spectacles for people in developing countries. I worked both in Zambia and in then Transkei and in both found large boxes of donated spectacles sitting in a corner. After a vain and time consuming attempt at accurate sorting I isolated the 'cataract' glasses and we let the patients choose the others to suit their requirements. Their delight was marvellous to see. Later I made contact with a firm in East London that provided a testing set and the spectacles at the very low price of R3 (about £1.50 then) each.I also visited an opthamologist friend in Botswana and was extremely impressed with the lens grinding workshop there. Three solutions to one problem. I was glad to see that our local recycling centre has a bin for spectacles and I hope they all find their way overseas.
I also agree with Dr Potter's dismay at the cost of unnecessary investigations in this country and the plea that we should have more faith in the expertise of our colleagues overseas.I contracted hepatitis A in the Transkei and was too ill to go anywhere but into my own ward. I had
excellent medical attention in the difficult prediagnostic days and the nursing could not have been better.Whenever asked I urge travellers who have some misfortune, a pyrexia or snake bite, to go to the nearest hospital. Local people know best how to deal with local problems.Every time
my hip dislocated in the UK it could not be reduced until my blood had been through the laboratory, I have no idea why.
There used to be a good dictum that you did not ask for an investigation unless the result would cause you to modify or change treatment. High time it was reinstated.
Yours etc
Anne Savage
7 Akenside Rd, London NW3 5RA
Competing interests: No competing interests
EDITOR- Andrew Potter's advocacy of easy access to cheap spectacles (1) is not a new idea, but it is one that still, unfortunately, needs to be pushed.
When I went to Malawi (then Nyasaland) in 1958 as a doctor looking after some Mission hospitals, I inherited from my predecessors a box of test lenses, and spectacle frames in which to fit them. Without specialist training, it was still easy to find out what spherical correction would help an individual with eyesight problems. Simple + or - spectacles could be obtained through a local supplier for one to two
pounds per pair. In the absence of ophthalmologists nearby, I also did occasional cataract extractions, and kept a supply of + 10 glasses for such patients. For an older woman to be able to see again to do her cooking was a great help to her.
David Stevenson, Honorary Fellow,
Department of Public Health Sciences,
University of Edinburgh Medical School,
Teviot Place, Edinburgh, Scotland, EH8 9AG.
1 Potter A. Providing spectacles in developing countries. BMJ 1998;317:551-2 (29 August.)
Competing interests: No competing interests
It has always seemed strange to me that medical students are not taught to do refractions in their undergraduate years. Recently I was involved in training indigenous physicians in Micronesia, and we undertook to demystify the process of assessing vision and prescribing spectacles.
An ophthalmologist taught us the technique of examining patients' eye glasses which had become damaged or for some reason unusable, using the lenses in a standard lens box (available from ECHO in the UK), and of measuring the distance between the pupils; and providing new glasses of the same power. We learnt to use the pinhole test and the lens box to do refractions, and we accessed hundreds of pairs of old spectacles which had been collected by one of the Service Clubs in the United States and Canada, which we classified and stored for easy retrieval.
We learnt a tremendous amount from this exercise, about how to use an opthalmoscope to measure the refractive error, and to identify the changes of diabetes and hypertension (common in that part of the world), and cataracts, as well as the early signs of xerophthalmia.
Referral was often out of the question, as we were working with populations living on isolated atolls, which were never visited by ophthalmologists, and which only received a visit from a physician "once in a blue moon".
We were faced with teaching the skills concerned to the local health workers permanently based on the islands; and this was another challenge which we overcame.
When we came to evaluate our performance, we were interested to note the uses to which peple put their glasses, particularly the elderly. There wasn't much reading material in the environments I am referring to, and we found that most of the men used the glasses to help them tie the knots for their fishing nets; the women used them in their sewing work.
All this went to show that it was really close-up glasses that elderly people need and appreciate. These are readily accessible in drug stores, as the article points out; but more importantly they can be made available with a minimal amount of professional know-how, which must mean some cost-saving somewhere.
Thank you for bringing this topic into "sharp focus".
Competing interests: No competing interests
I have worked for years in Niger, Benin's neighbour, in a mother and child clinic( PMI).I must confess I was focused on other ailments then bad vision.
I also remember not seeing many people with glasses, although there is no reason to believe their eyes to be far superior to Western eyes, so it is a pure problem of a huge unmet need.
Is there a way to help?
Renilt Van Gool, MD, MPH
Competing interests: No competing interests
Intraoperative lens implants are best in cataract surgery
Editor
We agree with Dr Potter that the provision of affordable spectacles
in developing countries could transform the lives of millions1. While this
is the appropriate remedy for children with refractive errors and adults
with presbyopia, people with cataracts would be better served by cataract
surgery with an intra-ocular lens implant. Simple intracapsular extraction
is of limited value; even in the developing world. Reports from KwaZulu in
Africa2 and Nepal3 indicate, that less than a quarter of patients ended up
using aphakic glasses, even when they were provided free. Thus cataract
blindness was merely replaced by uncorrected aphakic blindness. The use of
intraocular lenses leads to better results and a greater proportion of
satisfied patients, whilst also permitting earlier intervention. Most
importantly, early intervention prevents cataract blindness rather than
curing it. A major advantage is that the best advertisement for cataract
surgery (and the organisations and eye-camps offering it) is a satisfied
patient. More satisfied patients are likely to motivate more people to
come forward for surgery.
The high cost of intra-ocular lenses has been a limiting factor to
their widespread use in the developing world. Intra-ocular lenses are now
manufactured in India, Nepal and Eritrea for under £ 5 per lens, enabling
the cost of cataract surgery with lens implantation to be kept to around
£10. This is comparable to the cost of intracapsular catract surgery with
provision of aphakic glasses. A large randomised trial, in a developing
country setting4, has reaffirmed that extracapsular cataract surgery with
an intraocular lens is safer than intra-capsular cataract extraction and
that patients who received an intraocular lens reported greater benefits
and fewer problems with vision than those who received aphakic glasses.
Exemplary initiatives in Madurai 4 (India) and Tianjin5 (People's Republic
of China) have demonstrated that the practical difficulties which limit
the use of intraocular lenses in the developing world can be overcome.
Although cataract extraction without intra-ocular lenses is still
being widely performed in the developing world, all available efforts
should be directed to the incorporation of lens implantation into the
routine cataract surgery done there. Aphakic glasses should no longer be
considered an acceptable alternative for the developing world's cataract
blind.
Somdutt Prasad
Fellow, Department of Ophthalmology
Arrowe Park Hospital, Wirral, L49 5PE
Sanjiv Banerjee
Lecturer in Ophthalmology
University of Bristol, Bristol
Manish Nagpal
Fellow, Aso-Palov Eye Hospital
Shahibaug
Ahmedabad-380004, India
References:
Potter AR, Providing spectacles in developing countries(Editorial).
BMJ 1998;317:551-552 (29 August)
Cook CD, Stulting AA. Impact of sight-saver clinic on the prevalence
of blindness in northern KwaZulu. S Afr Med J 1995;85:28-9.
Hogeweg M, Sapkota YD, Foster A. Acceptability of aphakic correction.
Results from Karnali eye camps in Nepal. Acta Ophthalmol 1992;70:407-12
Prajna NV, Chandrakanth KS, Kim R, Narendran V, Selvakumar S, Rohini
G, Manoharan N, Bangdiwala SI, Ellwein LB, Kupfer C. The Madurai
Intraocular Lens Study II:Clinical Outcomes. Am J Ophthalmol
1998;125(1):14-25.
Lim AS. Eye Surgeons-Seize the Oppurtunity (Editorial). Am J
Ophthalmol 1996;122(4):571-573.
Competing interests: No competing interests