“Mission Netrotsav” Celebration of Sight Sarangadhar Samal Kalinga Eye Hospital Dhenkanal, India NYSASDRI, National Youth Service Action and Social Development Research Institute

Importance And Uniqueness “ One of basic human rights is right to see. We have to ensure that no person goes blind needlessly or being blind does not remain so, if by reasonable deployment of skills and resources his sight can be prevented from deterioration or already lost can be restored.”

Blind-Years Saved  The concept of “blind-years saved” postulates that restoring the sight of one child with pediatric cataract is equivalent to restoring sights of 10 elderly blind cataract individuals.  Blind-Years means number of blind multiplied by the length of life.  When the concept of blind-years is applied, blind children suffer an estimated 75 million blind- years, reinforcing the reality these children will face a lifetime of visual loss.

Why childhood blindness must be addressed  Although childhood blindness accounts for a small proportion of the blind population, it has been estimated that nearly a third of the global economic cost of blindness is due to child blindness.  Blind children have a lifetime of blindness ahead, which affects their opportunities for education, employment, and earning potential.  Early onset of blindness/diminished vision adversely affects psychomotor, emotional and social development.

Promoting good vision is important because…  During a child's first 12 years, 80 percent of all learning comes through vision.  Majority of students identified as problem learners have undetected vision problems.  Refractive error in children leads to poor academic performance and results in students dropping out of school.

The urgency..  According to WHO, 80% of blindness is preventable.  It is preventable through cost effective interventions.  If vision is not corrected by the age of 8 years, it causes permanent visual loss known as amblyopia (lazy eyes).  Blind children have a higher death rate than their sighted counterparts- 60% die within a year of becoming blind.

The prevalence of blindness is higher in India because: – potentially blinding conditions such as vitamin A deficiency, harmful traditional eye remedies, or cerebral malaria, which do not occur in affluent societies, are prevalent. – Preventive measures for conditions that have been controlled elsewhere such as measles, congenital rubella, or ophthalmia neonatorum are inadequate. – facilities and skilled personnel for managing conditions needing surgery are not always available. Blindness in India

40-45 million people are blind worldwide(WHO). 135 million people have low vision. In India,12 million people are blind. The major proportion remain in rural, remote and underserved areas. By the year 2020 the number of people who are blind and visually impaired will be twice the current level unless aggressive and innovative approaches are taken(WHO). Blindness: Some statistics

 1.4million blind children are present worldwide(WHO)  75% of the world's blind children live in developing countries (WHO).  Prevalence of childhood blindness in India is 0.17%.  Treatable refractive error caused 33.3% of the blindness, followed by 28.6% due to other preventable causes (16.3% due to vitamin A deficiency, 10% due cataract, 2.3% due to other causes). Childhood Blindness: Some statistics

 Odisha, a state in the eastern part of India, has been identified as one of the poorest states of India.  As per survey, Odisha has the highest percentage (47.15 %) of population living below poverty line.  It is also one of poorest performing states in India in terms of eye care service delivery.  Prevalence of blindness (2001) is 1.40%  Estimated blind persons in Odisha is 5.14 lakhs. Picture in Odisha

 Eye care in India faces several major challenges: ◦ lack of access for rural populations, ◦ unequal distribution of services, ◦ gross underutilization of available services, and insufficient facilities.  A public health strategy that addresses the issues of availability, accessibility, and affordability of eye care services is needed to address current problems and to meet long-term plans for reducing blindness. Need for Mission Netrotsav

 Pediatric eye care, which requires specialized training and equipment, is particularly lacking in rural Orissa.  As 91% of the population of Dhenkanal district lives in the rural areas, the same proportion of children who are blind or have significant refractive errors are living in the rural areas lacking in paediatric eye care & refraction services.  To improve the quality of life by reducing the avoidable blindness in the district of Dhenkanal, particularly among the children, an initiative has been launched in mission mode named MISSION NETROTSAV. Need for Mission Netrotsav

This project has been named after the ceremony in Odisha wherein Lord Jagannath gets His eyes painted every year. Meaning of Netrotsav

DISTRICT PROFILE:  11, 92,948 is the district Population and 1,32,647 is the number of children between 0- 6yrs.  1,701 schools & 2,042 Anganwadi centres are functioning in the district.  There are 3 ophthalmologists in Government health care set up and 3 in private /NGO set up.  That is one eye surgeon per 2,00,000 population.  7 Ophthalmic Technicians available in the Govt set up and one in private /NGO set up.

STRATEGY: The project requires the screening of the entire paediatric population of the district. District did not have enough ophthalmologists and ophthalmic assistants. It was decided to train the Anganwadi Workers (AWWs) and School Teachers with the proper technical skills required for screening children.

Highlights/Features of initiative  No extra financial requirement: ◦ The requisite funds for Screening kit is minimal (each kit costs INR Rs 60). ◦ Met out of School Improvement Grant (SIG) available to each school under Sarva Shiksha Abhiyan & ◦ Gaon Kalyan Samiti (GKS) funds available with Anganwadi Worker (AWW) under NRHM.  Last mile connectivity: ◦ Outreach for mass eye screening has always been a challenge due to paucity of Doctors & technicians. ◦ Therefore, AWWs and teachers were trained to do eye screening so as to reach out to the last child without the preliminary requirement of doctor / technician.

 Saturation and sustainability: – All the school- going and anganawadi children were screened through trained teachers/AWWs.  Continuous eye care: – Children can be screened regularly right from the date of their entry to AWC/ School.  Usage of glasses by the children is ensured: – Even though the doctor / technician prescribes and prepares the glasses, the usage of the same is ensured by AWW/Teacher since she is made to distribute the glasses to the children she has screened.

 Comprehensive eye care: ◦ The programme entails dispensation of Vitamin A supplements, medicines, glasses and surgery as per the requirement free of cost to the children. ◦ Through AWWs and teachers, Community can be empowered with regard to preventive, curative, rehabilitative and promotive aspects of eye care.  Detection at the reversible stage: ◦ According to WHO, 80% of blindness is preventable. If vision is not corrected by the age of 8 years, it causes permanent visual loss known as amblyopia (lazy eyes). ◦ Early detection and correction helps in optimal restoration of vision. Delay in detection would have led to sub-optimal restoration or blindness.  Improvement in behavioural and academic performance of the child: ◦ Correction leads to better behaviour and academic outcomes.

 Referral: – Complicated cases can be referred through District Administration to specialized hospitals.  Community awareness: – The trained teachers & AWWs – substantial in number – serve as the human resource to generate awareness on eye care issues among the community at large.

The protocol is simple and standardized so that it is replicable in other districts and can be up-scaled to include other segments of population. Implemented by harnessing inter-sectoral convergence, and in a public- private partnership mode.

TrainingScreening Treatment & Follow up The strategy was three pronged:

Sl.No. No. of SSA Staff engaged No. of ICDS staff engaged No. of Medical Staff engaged No. of Resource Persons engaged 1 Teachers: 1808 A.W. Workers: 1762 Ophthalmologists: 6 Govt. Eye Hospital Staff: 4 2 BRCCs: 08CDPOs: 8 Ophthalmic Assistants: 8 Kalinga Eye Hospital Staff: 3 3 CRCCs: 136 Supervisors: 48 BKM Rotary Eye Hospital Staff: 4 4 BRTs: 08 Details of staff who were involved is as shown in the table:

Mission Netrotsav

So that every child can see…

 The training manual was developed under the technical guidance of ORBIS International’s India office.  A teacher, preferably a science teacher was trained for screening.  She was trained for: ◦ Analysing complaints if any ◦ Checking for conjunctivitis, Bitots spots, corneal opacities ◦ Checking for cataract ◦ Squint using movements of eye ◦ Testing visual acuity using E chart.  She was handed over the screening kit which would be used for screening children in her school. 1.TRAINING

Anganwadi worker was trained to detect eye problems in children below 6 years. They used picture chart for this purpose. A toy which creates noise to attract the attention of the child was used. An ophthalmic technician with more than three years experience trained the teachers/AWWs in groups of each so that each teacher could be given individual attention.

AWW training programme

Demonstration of eye screening to AWWs

Training of teachers

 The training sessions were for a day and included theoretical instruction about common eye diseases and visual acuity, and practical demonstrations on measuring visual acuity, detecting cataract, squint, conjunctivitis, vitamin A deficiency etc. Training programmes

FFor conducting the training programme: DDistrict Headquater Hospital was assigned with 2 Blocks: ◦D◦Dhenkanal, ◦K◦Kamakhyanagar; KKalinga Eye Hospital was assigned with 3 Blocks: ◦K◦Kankadahad, ◦P◦Parjang, ◦H◦Hindol; BBKMM Rotary Eye Hospital was assigned with ◦B◦Bhuban, ◦O◦Odapada, ◦G◦Gondia Blocks. Block-wise Training

School teachers training session

School teachers: Hands on training

S. NoTopicDuration. 1Introduction & Orientation15 Min 2Anatomy of eye & its functions30 Min 3Common eye disorders in children30 Min 4Procedure for vision screening30 Min 5Procedure for vision screening for children between 6-16yrs ( for school teachers) Procedure for vision screening for children below five years ( for Anganwadi Workers) 30 Min 6Case Study10 Min 7Hands on Experience- A practical session45 Min TRAINING SCHEDULE.

Training session in progress

Teachers answering questionaire

Objective of the Eye Screening KIT Reduces burden on technical personnel. Empower community to take ownership of the problem. Through hands on involvement, increases awareness on common eye problems amongst community members / volunteers.

Target Groups School TeachersAnganwadi Workers School-going children between 6 to 15 years old. 0-3 year olds at home with their mothers 3-5 year olds at the Anganwadi centers School drop outs Adults > 45 years old 38

School Eye Screening KIT 6/9 line lettered “E- Chart” with clear instructions in the local language measuring tape eye care educational materials register pen referral slip screening process guideline Feedback Form 39

Snellen Chart versus 6/9 E Chart Snellen chart 6/9 line lettered “E- Chart” 40

The Process of School Eye Screening 1.Hold during the game period, like a game; so that regular classes aren’t disturbed and it does not require extra time after school. 2.Call students up one by one. 3.Ask the student whether s/he feels s/he has an eye problem. 4.Use a torch light to check for gross eye abnormalities and check to see if extraocular movements are intact and symmetrical. 5.Check visual acuity through E chart examination. 6.If any of the children test positive for any of the above, record their name into the register and notify the parents. 7.Follow up the cases in the register to ensure that the eye problem was treated and resolved. 8.Regularly repeat screenings throughout the year. 41

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Anganwadi Workers Eye Screening Kit eye screening chart measuring tape torch light noisy toy pen register referral slips eye care educational materials screening process guideline Feedback Form 52

Anganwadi Workers Eye Screening Charts 53

Benefits of 6/36 E-Chart This is meant to target adults with cataract The 6/36 line separates those who have functional impairment due to cataract between those who don’t. 54

Benefits of a Pictorial Chart Pictures of fun objects and games engage the interest of children. The broken ring can be used as a game for the school drop outs and children too young to read. 55

Process of 0-3 Year Old Screening 1.Go door-to-door and ask mothers to bring and hold their child for examination. 2.Ask the mother if she has noticed any eye problems with her child. 3.Torch light exam for gross abnormalities 4.Use the noisy toy for Extraocular Movements examination 5.Do the cover/uncover test for amblyopia 56

Benefits of Noisy Toy For children who are non-verbal, can be used as a fix-and- follow tool during the extraocular movement test 57

Cover Test 58

The Cover/Uncover Test The Anganwadi worker will use her hand to block each eye one at a time to look for any asymmetry in the child’s response. The child will cry or fuss more when the good eye is blocked. If the test is positive, the child may have some eye problems (amblyopia). The bad eye needs to be evaluated further and the child may need an eye patch. 59

Register, Referral Slip, Measuring Tape 60

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2. SCREENING:  After completion of the training, the teacher/AWW conducted screening in their respective school/ anganwadi centre.  The teacher/AWW began screening by taking detailed history of visual disturbances/ watering/ headache of the child.  They then examined the eye using torch to detect cataract/ corneal opacity/ conjunctivitis/ vitamin A deficiency. They detected squint after observing the movements of the eye. They assessed the visual acuity of each child in the school using an E chart/Picture chart (20/30 optotype) at 20 feet distance.  The school teacher held the eye examination in the school premises, without disturbing the school hours.

Marking distance for screening

Testing visual acuity

 The teachers categorized and listed children as – No Obvious Eye Problem and Need No Further Referral. – Need Further Referral. These children were given the referral slip. Results

TREATMENT AND FOLLOW UP:  Trained ophthalmic technicians subsequently screened the children identified as “Need Further Referral” by the school teacher.  The ophthalmic assistants examined the children at the Vision Centre of the concerned PHC individually.

Testing  The examination included : ◦A◦Analysis of presenting complaint ◦A◦Anterior segment examination of the eye ◦T◦Testing for ocular motility and alignment, ◦B◦Best corrected visual acuity, ◦R◦Refraction, ◦F◦Fundoscopy.

 The ophthalmic assistant prescribed spectacles for children identified with refractive errors.  The children identified with eye problems who needed examination by an ophthalmologist were referred to Kalinga Eye Hospital (KEH) & District Headquarter Hospital (DHH) and

 Children who were visually impaired were intimated to the District Office, Dhenkanal for rehabilitation.  Teachers and AWWs ensure that children use spectacles and follow up children who underwent surgery.  Post surgical follow-up done by technicians and doctors. Follow up

We have categorized outcome in three different categories: OUTCOME: MedicineRefractive ErrorSurgeryRehabilitationFollow-up

TRAINING: Training Report on Eye Screening S.NoBlockTeachers proposedTeachers attended% 1Hindol Parjang Sadar Gondia K.Nagar Bhuban K. Had Odapada

Training Report on Eye Screening S.NoBlockAWWs proposedAWWs attended% 1Hindol Parjang Sadar Gondia K.Nagar Bhuban K. Had Odapada

No of children screened S.NoBlockTAWWTotal 1Hindol23,44814,47337,921 2Parjang19,59810,43830,036 3Sadar26,52812,19038,718 4Gondia24,82813,79038,618 5K.Nagar16,77810,04826,826 6Bhuban18,6658,83427,499 7K. Had17,92310,19928,122 8Odapada18,28210,86129,143 Total1,66,05090,8332,56,883

S.NoBlock Total 1 st round Total 2 nd round 1Dhenkanal Bhuban K.Nagar Parjang K.had Hindol Odapada Gondia Total Details of screening

Children identified for surgery S.NoBlock Total children identified for surgery 1Dhenkanal Bhuban K.Nagar Parjang K.had3710 6Hindol Odapada Gondia7815 Total

Details of Abnormalities Detected are as follows: Details of Abnormalities Detected are as follows:

Distribution of eye abnormalities in each block. Gondia Block Parjang Block Eye Problems% of Children affected with Blind2.6 Cataract1.5 Conjunctivitis6.0 Corneal Opacity2.3 Refractive Error27.2 Squint14.7 Vitamin- A Deficiency5.7 Eye Problems% of Children affected with Blind1 Cataract1 Conjunctivitis8 Corneal Opacity1 Refractive Error24 Squint3 Vitamin- A Deficiency7

Distribution of eye abnormalities in each block Bhuban Block Hindol Block Eye Problems% of Children affected with Blind1.1 Cataract1.7 Conjunctivitis11 Corneal Opacity3 Refractive Error23 Squint9.6 Vitamin- A Deficiency7.6 Eye Problems% of Children affected with Blind1.1 Cataract2.9 Conjunctivitis3.8 Corneal Opacity3.8 Refractive Error11.3 Squint3.4 Vitamin- A Deficiency7.1

Distribution of eye abnormalities in each block Kankadahad Block Kamakyanagar Block Eye Problems% of Children affected with Blind0.3 Cataract3.4 Conjunctivitis2.8 Corneal Opacity2.0 Refractive Error13.0 Squint12.8 Vitamin- A Deficiency1.4 Eye Problems% of Children affected with Blind0.5 Cataract1.1 Conjunctivitis15.1 Corneal Opacity1.1 Refractive Error14.9 Squint0.7 Vitamin- A Deficiency1.4

Distribution of eye abnormalities in each block Dhenkanal Block Odapada Block Eye Problems % of Children affected with Blind 0.8 Cataract 1.9 Conjunctivitis 13.2 Corneal Opacity 0.6 Refractive Error 16.0 Squint 4.7 Vitamin- A Deficiency 4.7 Eye Problems% of Children affected with Blind0.3 Cataract2.8 Conjunctivitis5.9 Corneal Opacity2.1 Refractive Error13.3 Squint12.2 Vitamin- A Deficiency2.1

SNoBlockSpectaclesMedicine Sum Sum 1Dhenkanal Bhuban K.Nagar Parjang Kankadahad Hindol Odapada Gondia

SURGERY  261 children for whom surgery was required were identified.  94 children were operated.  Of the rest, some were found too young for successful surgery and advised to come at a later date after some years when the child was older.  Parents of some children refused surgery in spite of counselling.  36 children were referred to LV Prasad Eye Institute, Bhubaneswar, where surgery is being taken up in phases.

Child undergoing eye surgery

Pediatric eye ward

S. NoName of the Hospital Total 1Surgery Conducted at Kalinga Eye Hospital, Dhenkanal Surgery Conducted at LV Prasad Eye Institute, Bhubaneswar 44 Total Table showing the details of treatment

 46 blind and low vision out- of- school- children were detected.  For the first time in the State, a special 10 month Residential Braille Literacy Camp (School Readiness Camp) was started for 28 blind children on 20 th December 2010 at Special School for Blind in Dhenkanal, so that they can be made eligible for mainstreaming.  The rest 18 low vision children were admitted to their nearby general school. Rehabilitation

 Before the launch of Mission Netrotsav, the screening camps were conducted only by the ophthalmic assistants and doctors.  Majority of the population was not covered.  Before the launch of Mission Netrotsav, pre- school children were hardly screened.  The outreach camps organised by the Government and Non Government hospitals were few and far between. Outcome Before and After

YearNo of children screenedNo of children with refractive error , , , , Total38,5341,799 Scenario before Mission Netrotsav

No of children screenedNo of children with eye defects Sept 2009 till date2,56,8834,494 Outcome after Mission Netrotsav

OOphthalmic assistants and doctors are also conducting screening camps for target groups which are less likely to come under medical care like: – Tribal villages, –W–Weavers & artisans, –P–Periphery villages of industries/mines, –L–Labourers, –S–Social security pension beneficiaries, –S–Slum pockets in urban areas. Adult segment

 Particular mention can be made regarding Modified Area Development Agency (MADA) area.  It consists of 52 tribal villages of the Kankadahad block.  During June 2010, a total of 48 screening camps were conducted.  1077 people have attended the camp out of which 201 have undergone the cataract eye surgery. MADA Eye Screening Camp

 On the pension distribution day ie15 th of every month eye screening of elderly patients by health worker (M) and Health Worker (F) of concerned health sub centre.  Ophthalmic Assistant are deployed for each block for eye screening of elderly patients.  Plan has been prepared for transportation of cases from block level to DHH. Screening for elderly patients

Screening in MADA area

Screening elderly people

Cataract surgery in progress

Similarly, with the collaboration of Corporate houses, camps were organised in industrial periphery villages. S NoName of our PartnerNo of camps No of patients screened No of Patients Provided with Medicines No of Patients Provided with Glasses No of patients operated 1 GMR Foundation, Dhenkanal BRG Iron & Steel Co. (P) Ltd, Dhenkanal Mangilal Rungta, Dhenkanal Rungta Mines Limited, Dhenkanal Lanco Foundation

S NoName of our PartnerNo of camps No of patients screened No of Patients Provided with Medicines No of Patients Provided with Glasses No of patients operated 6 Nava Bharat Ventures Bhushan Steel TOTAL Camps in industrial peripheral areas (cont)

Adult segment  2,489 surgeries were done for the year  3,295 surgeries were done for the year

 1960 SSA functionaries and 1818 ICDS functionaries (total: 3778) trained to do eye screening at community level.  2, 56,883 children were screened.  261 children were identified for surgery: 94 children underwent surgery.  637 children were dispensed with medicine. 628 children with serious Vitamin A deficiency were given therapeutic dose of Vitamin A.  5,784 adult surgeries conducted.  46 out-of-school blind/low vision children were identified and mainstreamed. OUTPUT

 Training of ASHAs in eye screening.  Training ANMs in eye screening of newborn and infants during immunization.  Training of the Inclusive Education Volunteers on detection of eye problems.  Refresher training of the School Teachers / AWWs.  Regular Eye screening Report from the school & Anganwadi Centre. Plans for Sustainability

 Follow up of the children who were treated medically or by surgery.  Every school has been instructed that during enrolment of a new child, her eye examination must be done by the trained teacher.  Providing teachers/ AWWs with incentives would be explored as per NPCB-DBCS guidelines.  Involvement of print and electronic media.

Thank You. Kalinga Eye Hospital