Eye on the future: Giving our children a ‘bright’ futureFebruary 16, 2021
By S Ramadorai, Arvind Singh & Indrajit Shaw
Healthy eyes and vision are a critical part of a child’s development. Visual defects have a considerable impact on the lives of the affected individuals as well as their families and society. Its effect on development and learning is more significant when it is present at birth or develops shortly afterwards, compared to when it is acquired later in life. Vision problems are common among school-age kids. Loss of vision in children influences availing of academic opportunities, career choices, and social life. Vision plays a fundamental role in acquiring skills such as language, interpreting facial expressions, and skills requiring hand-eye coordination.
Timely and periodic screening of visual defects is critical for planning early intervention. Appropriate estimation of the visual function, detection of refractive error, retinopathy of prematurity, congenital structural anomalies, congenital dacryocystitis, corneal scar, glaucoma, cataract, retinal abnormalities, retinoblastoma, strabismus, and amblyopia are some of the crucial components of screening in children. Test protocols vary from country to country, and some have mandated screening at birth and periodical review thereafter.
In most developed countries, there exist programmes to screen children aged 3-4 years for visual defects. This is done to ensure that defects like squint and amblyopia are identified early and rectified before the age of 8 or 9, avoiding the certainty of the child having ‘defective’ vision for life. In most cases, such defects are only identified when the person goes for a formal vision assessment prior to a driving test or joining the armed forces. By that time, it is too late to reverse the damage, denying the opportunity of pursuing a career of choice.
In India, it is estimated that one in 1,000 aged 0-15 years are blind. The Rashtriya Bal Swasthya Karyakram (RBSK) programme of the National Health Mission, which evaluates a child’s health, includes screening for visual disorders. However, limitations of equipment and ophthalmologists allow only for a test for refractive error. The programme has been designed primarily to identify developmental delays (usually associated with a neurological deficit) in early childhood. It does not specifically identify visual impairment in children under 4-5 years of age.
Identification of common visual defects such as amblyopia after the age of 7 or 8 years makes their rectification very difficult. Unlike hearing defects which need to be identified at, or soon after birth, visual defects are best identified just before a child starts school or formal education. The RBSK programme implemented by the government is also geared towards identifying defects at birth, deficiencies, diseases and developmental delays including disability. Therefore, a programme aimed at picking up refractive errors and amblyopia at the age of 4-5 years, offers great ‘value for money’.
Health-tech startups have developed innovative apps that measure various aspects of a child’s vision by making a child feel that they are playing a computer game on the smart device; meanwhile, the app gathers data in the background. These apps can also be customised to test additional components of vision, like colour perception and binocularity. With the increasing penetration of internet and smartphones, the potential to use such apps to assess more healthcare parameters, like hearing in the newborn, exists.
These devices can be used by healthcare visitors, community workers and even teachers. The cost of these devices can be further reduced if they could instead be hosted online, making them available to people across the length and breadth of the country. Internet-based access will also allow these applications to be frequently updated and customised into several regional Indian languages.
Thus, it is imperative that effective strategies be developed to eliminate avoidable and treatable causes of childhood blindness. Strategies to address the eye health of children during the early years of life have, therefore, focused on school eye health programs. Considering these aspects, innovative community-based strategies are required to provide quality services to the underserved sections of the community. Introducing teachers as the first component of the school eye screening programme, especially in rural areas, can lead to the effective utilisation of existing resources and early detection of potentially blinding disorders in children.
The common causes of correctable suboptimal vision in a child are amblyopia, uncorrected refractive error, and visual perception disorders—this is as high as 1 in 50 children. Amblyopia is where the eye is structurally normal, but the vision is low. This occurs when the images being projected on to the retina of the two eyes are significantly different. If uncorrected, these conditions could lead to the eye having a permanently reduced vision, But, with early detection, it can be rectified to restore full and normal vision.
The identified refractive errors can be easily corrected with a pair of spectacles, especially for a child of a lower age group, and testing can be done with simple tools devised. With the use of new technologies, screening of children for visual defects can be expedited and treated at the right time. In our view, the following institutes can be partnered with, in a PPP mode, by the health department for providing a solution for early detection of visual defects in children.
LV Prasad Eye Institute (lvpei.org): LV Prasad Eye Institute have devised a very low-cost device to detect refractive errors and give a prescription that can measure long or short-sightedness so that spectacles may be provided to correct the refractive error and restore clear vision.
Vision Spring (visionspring.org); Vision Spring is a charitable organisation that distributes spectacles at a very low cost (approx. $3-4 per pair). They provide glasses in a certain geographical area, in accordance with the funder donor’s wishes.
OKKO Health (okkohealth.com): OKKO Health is an organisation that is set up by a bright young Optometrist, Stephanie Campbell, to design apps for the smartphone to assess children’s vision. They have devised apps that measure visual acuity, contrast sensitivity, squint and colour vision in children. The child plays a game on the smart device, unaware that the data being captured gives the required assessment of the various vision parameters.
For an effective and comprehensive way forward on visual screening of defects in children, we could adopt a two-step approach. The first will be a pilot that will enable us to put in place a structure with the help of identified stakeholders, with a short to medium-term perspective. The second will see the actual screening system implementation and rollout across the country (preferably statewise), to iron out the problems from phase one and establish a long-term presence.
The successful implementation of the strategy will involve a partnership between state government agencies, NGOs, trusts and charities. A teaching hospital or an academic centre will have to be identified in each geographical area so that patients, who cannot be helped with spectacles alone will be referred for further management. The referral system will also be organised on a ‘hub and spoke’ model, with a large centre being established as a hub and smaller, preferably academic, centres being considered spokes. Screening areas could be decided along geographical regions around the ‘spoke’ so that each child, identified for further diagnosis, does not have to travel long distances for the initial consultation and subsequent monitoring.
Ongoing data collection and analysis will ensure that no child ‘drops out’ of the system and real benefits of the system can be demonstrated and quantified. A successful implementation will enable identification of correctable visual problems in the 3-4-year age group and rectify the defects. They will enable the visually impaired children to achieve their full potential in life with good vision. A beautiful quote I once read said, “If we could all see the world through the eyes of a child, we would see the magic in everything.”
Ramadorai is former VC, Tata Consultancy Services, Singh is ophthalmic surgeon & CEO, Eternitii Ltd and Shaw is senior principal consultant, Genpact