In this first issue of COOKIE, our cover story takes a look at the imbalance in access to eye care in Asia-Pacific, as well as future considerations for improvement. COOKIE magazine is designed to help increase optometric and optical awareness and education worldwide, with a special focus on countries in the Asia-Pacific region.
Around the world, there are major inequalities when it comes to access to vision and eye care. This tends to affect the lower-income, or more rural regions disproportionately, where access to simple vision screening and spectacles can be cost-prohibitive, leading to higher rates of myopia and presbyopia. Meanwhile in higher-income countries around the world, the more likely causes are age-related, like cataract and age-related macular degeneration (AMD).
According to the World Health Organization’s (WHO) World Report on Vision1, there are 2.2 billion people with visual impairment globally — and at least 1 billion of those cases could have been prevented, or have yet to be treated. Unaddressed presbyopia (826 million) and uncorrected refractive error (123.7 million) are the most common cause of preventable blindness worldwide. On further investigation, countries in Asia-Pacific own a disproportionate share of the burden.
The WHO report stated: “The economic burden of uncorrected myopia in the regions of East Asia, South Asia and Southeast Asia were reported to be more than twice that of other regions — and equivalent to more than 1% of gross domestic product.” This illustrates widespread visual disability in the region, which is also associated with decreased productivity and quality of life (QoL).
However, lack of access to care isn’t the only problem in Asia-Pacific — in fact, the prevalence of myopia is the highest in high-income countries in the region (53.4%). For example, in-country numbers among adolescents in urban China and South Korea are quite startling, with myopia rates of 67% and 97%, respectively.1
In addition, low vision that cannot be corrected with spectacles, contact lenses or laser surgery is also comparatively higher in lower income countries in Asia-Pacific.2
Therefore, in the premiere COOKIE cover story, we take a look at disparities and barriers to eye care in Asia-Pacific, with insight from an Asia-based optometrist on how to improve access — and thus, improve vision — in the region.
The Imbalance is Great
Back at Asia-Pacific Academy of Ophthalmology (APAO) congress in 2017, Dr. Taraprasad Das (India) presented the Holmes Lecture, titled: Blindness and Visual Impairment Profile and Rapid Assessment of Avoidable Blindness (RAAB) in Southeast Asia: Analysis of New Data.3 What he revealed was very telling of the situation on the ground in Southeast Asia — and is still relative today in 2020.
The International Agency for Prevention of Blindness (IAPB) includes 11 countries in its Southeast Asia region (SEAR) — in this region, 12 million are blind and 78.5 million are visually impaired; this amounts to 30% of global blindness and 32% of global visual impairment, according to Dr. Das.
His analysis included moderate to severe vision impairment (MSVI) and blindness from eight SEAR countries: Bangladesh, Bhutan, India, Indonesia, Maldives, Sri Lanka, Thailand and Timor Leste. Not included were Myanmar, Nepal and North Korea.
In all eight countries, cataract was the primary cause of blindness (presenting visual acuity (PVA) worse than 3/60) and severe visual impairment (PVA worse than 6/60). However, in four countries, uncorrected refractive error (URE) was the primary cause for moderate vision impairment (PVA worse than 6/18): Sri Lanka (64%); Bangladesh (63.6%); Maldives (50.9%); and India (32.9%). And although cataract is the main cause of moderate visual impairment in Bhutan, Indonesia, Thailand and Timor Leste, the rates of impairment from URE are still concerning at 34.7%, 36.8%, 26.7% and 32.2%, respectively.
URE also accounts for higher levels of severe impairment in Sri Lanka (46.7%) and Thailand (26.7%). In addition, URE accounts for 12.5% of blindness in Sri Lanka. Although these statistics are unsettling, there is a bit of good news: Progress is slowly being made. The RAAB survey noted that the prevalence of both blindness and MSVI has reduced from 1990 in [the region], though it was higher than the world average, according to Dr. Das.
Among the barriers noted, accessibility was the biggest hurdle in Maldives and Timor Leste. In Sri Lanka, the primary barrier was cost.
“In addition to accessibility and expenses, we identified two further barriers to effective eye care delivery in the Southeast Asian region in an earlier publication; they were lack of human resources and the urban centric distribution of eye care personnel,” said Dr. Das.
To address accessibility, Dr. Das said points of care could be placed “as close as possible to people through the eye health pyramidal system of service delivery.” Further, expenses could be met either by national eye care subsidies or appropriate health insurance, he continued.
“However, the key will always remain in human resources and equitable distribution of skilled eye health personnel,” shared Dr. Das. “We strongly believe that training and deployment of allied eye health personnel hold the key to reduction of preventable blindness.”
Spotlight on the Philippines
The top reason for blindness in the Philippines is cataract: “People don’t have access to eye care and/or they don’t have money to visit the doctor. Cataracts are still the number one cause of preventable, avoidable blindness in the Philippines,” said Dr. Carmen Abesamis-Dichoso, a self-employed optometrist in private practice at Medical Plaza Makati and a COOKIE advisory board member.
The second is URE. She says many people in the Philippines can’t afford to buy eyeglasses, which cost about US$4. “They don’t have glasses because they don’t have food on the table. Eyeglasses are a luxury for them.”
Myopia is also on the rise due to changes in lifestyle, especially among those in urban areas. “About 52% of the population in the Philippines is potentially myopic . . . everyone is taking online classes and working online — and this is adding to the risk,” she said. “Myopia is the other pandemic.”
And while the Philippines enjoys the longest history in optometry in the Asia-Pacific region, with its first law enacted in 1917, this nation of more than 7,000 islands has issues with accessibility.
In the Philippines, distance to vision services is the biggest barrier, according to Dr. Abesamis-Dichoso: “It’s very dispersed, so it’s not balanced when it comes to accessibility or availability.
“People from far-fetched islands, they have to take a boat, a land trip and then another boat, just to get to the city and that’s very challenging to them,” she continued.
Another issue is economics — for both physicians and patients. “Optometrists and ophthalmologists are more attracted to practicing in the cities — you would rarely see an optometrist or ophthalmologist going to those provinces,” said Dr. Abesamis-Dichoso, adding the reason for this is that there isn’t the same earning capacity in the remote villages and islands.
Further, Dr. Abesamis-Dichoso says that many Filipino optometrists are working overseas: “Compared to the rest of Asia-Pacific, we are very much ahead in terms of education. About 70-80% of optometrists working in the Middle East are Filipino,” she explained, adding that Singapore also employs many Filipino optometrists. “They have a very high prevalence of myopia — up to 80% — but they don’t’ have a lot of optometrists.”
On the Plus Side
Although challenges remain, there are philanthropic groups — as well as dedicated volunteers — who are helping to lessen the burden and alleviate some of the region’s preventable blindness.
One such example is the Fred Hollows Foundation, an international development organization whose purpose is to make sure everyone — whether they’re rich or poor — has access to high quality, affordable eye health care. The Foundation’s work continues the mission of Prof. Fred Hollows, whose vision was to end avoidable blindness.
According to Dr. Abesamis-Dichoso, the Foundation identified six areas in the Philippines and “put up” eye centers there. “There are volunteer optometrists and ophthalmologists who visit the eye center — and it’s attached to a hospital. This means that at least three to four times per week there is access to eye care in some provinces. There are three in Luzon, but I don’t think there are any in Manila yet,” she shared.
The Philippine government has also been active in this regard, by promoting vision screening, teaching health workers to perform vision screenings, and focusing on education.
Charitable organizations, along with continued education and awareness of preventable blindness, will certainly help make strides to eradicate vision impairment in the region. Improvements have already been made, and with the combined efforts and commitment from those in the industry and beyond, more and more people will finally have access to eye care in Asia-Pacific and around the world.
- World Report on Vision, 2019. World Health Organization. Available at: https://www.who.int/publications/i/item/world-report-on-vision Accessed on October 26, 2020.
- Chiang PP, Marell M, Ormsby G, Keeffe J. Critical issues in implementing low vision care in the Asia-Pacific region. Indian J Ophthalmol. 2012;60(5):456-459.
- Taraprasad D. Blindness and Visual Impairment Profile and Rapid Assessment of Avoidable Blindness in South East Asia: Analysis of New Data. 2017 APAO Holmes Lecture. Asia Pac J Ophthalmol (Phila). 2018;7(5):312-315.